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ADM Reconstruction Medical Policy Changes - Dermacell

Big changes to Acellular Dermal Matrix (ADM) Medical Policies!

As an aside - we are not affiliated with, making any recommendations regarding, or suggesting superiority of brands in any way.

For a long time, Alloderm has been the only allowed ADM.  Other venders and brands have been considered "experimental."  Dermacell, another prevalent brand in the marketplace, has recently broken through the med pol end here and gotten approved as medically necessary with the majority of the major payers.

Why does this matter?

Many providers often use non-approved or "experimental" brands in surgery.  These brands may be equivalent or beyond in terms of real world efficacy, but medical policy updates move slow.  If a surgeon utilizes an "experimental" substance, it may be paid because the reviewers don't catch it or don't even ask for records.  The risk here is massive.  Hospitals are often unforgiving in their billing of patients and that is exactly where the bill tends to land so be careful!

What if the brand I like isn't approved?

Our stock response is don't risk it without backing from the vender to cover the cost.  The medical policy being dated or wrong isn't going to change things.  Feel free to work with the vender on pushing for approval if you would like to help, but until the substance is approved, don't risk it.

We have a few other tips and tricks too so feel free to reach out for further info!  Feel free to call me directly! 

 

John Gwin

Founding Partner

708.669.9313

jgwin@theauctusgroup.net

 

Which insurance companies are covering Dermacell?

Aetna – Medical Policy: Breast Reconstructive Surgery, Policy # 0185: http://www.aetna.com/cpb/medical/data/100_199/0185.html

Cigna – Medical Coverage Policy: Breast Reconstruction Following Mastectomy and Lumpectomy, Policy # 0178: https://cignaforhcp.cigna.com/public/content/pdf/coveragePolicies/medical/mm_0178_coveragepositioncriteria_breast_reconstruction_follow_mast_lump.pdf

UnitedHealthcare – Medical Policy: Breast Reconstruction Post Mastectomy, Policy #CDG.003.09: https://www.uhcprovider.com/content/dam/provider/docs/public/policies/comm-medical-drug/breast-reconstruction-post-mastectomy.pdf

Anthem – Medical Policy: Allogeneic, Xenographic, Synthetic and Composite Products for Wound Healing and Soft Tissue Grafting. Policy # SURG.00011:https://www.anthem.com/medicalpolicies/policies/mp_pw_a053309.htm

Press Releases:

LifeNet Health Press Release regarding Dermacell coverage, Anthem: https://www.prnewswire.com/news-releases/lifenet-healths-dermacell-acellular-dermal-matrix-receives-anthem-coverage-300603527.html

LifeNet Health Press Release regarding Dermacell coverage, Cigna: http://www.prnewswire.com/news-releases/dermacell-receives-coverage-from-cigna-300411026.html

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Modifier 25 Reduction for Same Day Services Rolled Back

A very significant step in the pushback against the trend of slicing into physician revenue by insurance carriers was taken this month as Anthem rescinded its January 1, 2018 policy for same day services.  Previously the policy intended to reduce E/M reimbursement by 50% when rendered on the same day as qualifying procedures.  After a push by physicians, this policy has been rolled back to March 1, 2018 and from 50% to 25%.  Continued efforts by physicians and the AMA will hopefully put a complete stop to the policy altogether, but that is left to be seen.

AMA Article link below here...

https://wire.ama-assn.org/practice-management/win-doctors-anthem-rescinds-pay-cut-same-day-services

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BCBS IL Pre-Auth Changes for 2018

Some pretty major changes to pre-auth requirements for BCBSIL.  This means that authorization staff will have to submit every time for approval.  Please keep in mind how this will impact booking timelines.

 

Notable changes:

 

19318 - Breast Reduction - Best practice has been to submit for pre-determination regardless so not a massive impact here.

 

211XX - CMF - Many craniomaxillofacial midface reconstruction codes now require authorization, which will be a bit of a change.  Given most of these cases may be rendered in emergency situations, hopefully not a huge process change for most of us.

 

30520 - Septoplasy - probably the most notable change as no review was previously required.  This will push back booking time frames for septorhinos.  For those practices booking prior to obtaining authorization please be sure to keep a close eye on this change.

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