VITURO HEALTH MEDICARE ELITE ACCESS PROGRAM
Effective July 1, 2017 Medicare issued a Temporary C-Code C9747 for facility coverage ONLY.
- As of today, most MACS are reimbursing, for out-of-pocket cost to a patient please contact a Vituro Health patient care coordinator. This is something we monitor closely with each jurisdictional MAC.
- Facilities covered are Hospital Outpatient Facility or Ambulatory Surgery Center (ASC)
- C9747, for the ablation of the prostate, transrectal, high intensity focused ultrasound (HIFU) including imaged guidance.
- This procedure being assigned a HCPCS code and a payment rate under the OPPS does not imply coverage by Medicare.
- Assigns a value if the Medicare Administrative Contractor (MAC) determines it meets requirements for coverage. (11 MACS)
- MACs make determination for all settings – Hospital, ASC and HOPD
WHAT IS A C-CODE?
- C-codes are unique temporary pricing codes established by CMS, and apply only to the hospital outpatient setting, while some C-codes also are payable in the ambulatory surgery center setting. They are separately payable and should be reported and billed together with the appropriate current procedural terminology or health-care common procedure coding system code.
WHAT DOES CODE C-9747 COVER?
- Facility (hospital, ASC or outpatient facility)- where the procedure is performed.
WHAT DOES MY OUT-OF-POCKET COSTS COVER?
- Vituro Health HIFU physician-who performs the HIFU procedure.
- Anesthesiologist-delivers anesthesia
- Vituro Health Patient Advocacy Center
Please contact the Vituro Health Care Center for more information.
Is HIFU covered by commercial insurance plans?
Currently, CIGNA is the only insurance carrier to announce coverage for High Intensity Focused Ultrasound (HIFU). However, this coverage is limited to patients who have a recurrence of prostate cancer post-radiation treatment (see coverage criteria below). All other insurers evaluate HIFU on a case by case basis and many of our patients have received reimbursement post procedure.
The Vituro Health Care Team, with assistance from the Vituro Insurance Team, will work with each patient to evaluate their policy, then assist in maximizing reimbursement. Vituro Health physicians have excellent success rates which can be a factor in reimbursement from carriers.
CIGNA HEALTH HIFU COVERAGE CRITERIA
The CIGNA policy covers HIFU as a salvage therapy for patients whose early stage prostate cancer has not metastasized and who meet both of these criteria:
- positive, recent (i.e., repeat) transrectal ultrasound guided (TRUS) biopsy completed due to suspicion of local recurrence of prostate cancer
- candidate for local therapy alone as evidenced by ALL of the following:
- original clinical stage T1-T2, NX or N0
- recent PSA (Prostate Specific Antigen) of less than 10ng/mL
- absence of distant metastases
Many patients work for large companies who are self-insured and have more flexibility with coverage versus a standard insurance product. Talk to your HR department to find out if your company is self-insured and the process you must follow to seek reimbursement. The Vituro Health Care Team will assist you in working through the benefit with your company. Vituro Health patients have seen the highest percentage of reimbursements from self-insured employers.