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
