Sign-On to Support an Increase in Medicare Reimbursement for Facial Fillers

April 8, 2011

Sign-On to Support an Increase in Medicare Reimbursement for Facial Fillers

A prominent AIDS activist is asking people with HIV and the organizations that serve them to sign on to a letter asking the agency that sets reimbursement rates for Medicare to boost the rate it offers doctors to administer the facial fillers Sculptra (poly-L-lactic acid) and Radiesse (calcium hydroxylapatite).

Activists thought they’d won a major battle when the Center for Medicare and Medicaid Services (CMS) announced in March 2010 that the government health insurance program would begin covering the costs of Sculptra and Radiesse for people who have psychological trauma due to loss of fat in their faces, a condition known as lipoatrophy or facial wasting.

Sculptra and Radiesse are both temporary facial fillers that require touch-ups at least once per year for most people. The retail cost of a vial of Sculptra or Radiesse usually tops $500. As most people need a minimum of four to six treatments, and as doctors charge about $500 to $900 to inject the filler, a full course of treatment can easily exceed $4,000.

It’s the latter point, reimbursement for the physician’s fee, that has Nelson Vergel, a longtime AIDS activist from Houston, and other activists up in arms. Though doctors typically got $500 or more per treatment from their cash-paying patients to inject the facial fillers, Medicare is typically reimbursing only about $80. Obviously, the math doesn’t add up.

“The cost of acquiring and administering the product is higher than the payment amount set by Medicare,” he explains in the letter he’s asking people to sign on to. “As a result, physicians are not accepting Medicare payments for this service, and patient access to these effective therapies remains quite limited at the current reimbursement rates.”

To sign on to a letter demanding that Medicare increase its reimbursement rate for Sculptra and Radiesse treatment, click herebefore April 18.

Medicare seeks comments from community and clinicians about facial lipoatrophy reimbursement needs

For everyone who has complained about the lack of insurance
reimbursement for facial lipoatrophy treatment, or about the lack of
good permanent fillers approved for facial lipoatrophy, now is your
chance to do something. Please follow the link below
to submit a comment in response to Mediare's request for comments on
Reconstructive Treatment for Facial Lipodystrophy Syndrome. Even if
you have private insurance, private insurers are likely to follow the
lead of Medicare, the country's largest health program. Manufacturers
of facial fillers are more likely to seek FDA approval if there is a
potential for insurance reimbursement for their products. This is
probably the best opportunity we've ever had to do something about
insurance reimbursement for facial wasting procedures. With a new,
more enlightened administration in the White House, I think there's a
good chance that Medicare will change its policies in response to
reasonable arguments that treatment for facial wasting is
reconstructive (like reconstruction of a breast after breast cancer or
like surgery to eliminate disfiguring burn scars).

Powerful personal anecdotes about how facial wasting has affected you
are likely to be persuasive, particularly if you can talk about how it
has caused social isolation or impaired your ability to work. Pictures
will speak louder than words; if you have pictures of your face
before and after treatment for facial wasting, posting them with your
comments could help the cause enormousely. There is an email link on
the form for attachments.

If you choose to write personal anecdotes or submit pictures, the
government will redact (delete) anything you write about your personal
experience with facial lipoatrophy from the comments posted on the
website, and will not post personal photos (before you can comment,
you are required to read a statement from the government stating that
statements about personal health conditions will not be posted on the
website). But presumably, these comments (and photos) will still reach
the intended decision makers in the government in their unredacted
form. I personally chose to begin with a paragraph that stated my
opinion about the proposed change to policy and then discussed my
experience from working with people with HIV. Presumably, these
comments will be posted on the website. Then I went on to describe my
personal experience with facial lipoatrophy, providing a couple of
anecdotes that I thought demonstrated the effect it has had on me. I
presume these comments will not be posted, although I don't really
mind if they are.
Please click on the orange "comment" button to explain to Medicare why you think facial lipoatrophy is a medication-induced side effect that needs to be treated and covered. If you can add your own personal experience as a patient or as a clinician, even better!

We do not have much time. The deadline is Feb 16

http://www.cms.hhs.gov/mcd/ncpc_view_document.asp?id=20


For more information about facial reconstruction products in HIV, please visit facialwasting.org

How do I get my insurance to pay for my facial wasting treatment?

How do I get my insurance to pay for my facial wasting treatment?
Jun 28, 2008
Hello Nelson-

I hope this finds you well. I wanted to check in with you to see if you were aware if there is any insurance coverage for silicone treatments for facial wasting. I have had several sessions, and it works great. It is not cheap, of course. I am in need of a refresher treatment. I should mention that my insurance is Medicare A,B and D. I receive my meds through a Blue Cross-Part D plan, backed up by ADAP.

Neal



Response from Mr. Vergel

Neal,

It is difficult to get reimbursement for Silikon 1000 since it is an off-label use for facial wasting, but you have nothing to lose and a lot to gain if you have your doctor write a medical necessity letter to send to your insurance company.

Here is a letter that Dr. Doug Mest wrote for my web site facialwasting.org for Sculptra. You can have your doctor use this letter as a template and also to use these scientific references. You can also visit the wonderful resource guide that TheBody.com has created for trying to get coverage for facial lipoatrophy reconstruction options from your insurance:

http://www.thebody.com/lipo/insurance.html

References for silicone and facial lipoatrophy:

http://findarticles.com/p/articles/mi_m0PDG/is_2_4/ai_n13559216

SAMPLE LETTER:

Insurance Co Name

Insurance Co Address

Patient Name

Subscriber #

Date

To Whom It May Concern:

This letter is written in regards to the medical necessity of restorative treatment for the facial deformities this patient suffers from secondary to HIV-Associated Lipoatrophy. Facial fat loss is the most devastating aspect of this condition as it can not be disguised by clothing or other means. Although the exact underlying mechanism of HIV-Associated Lipoatrophy is unknown (1), the devastating effects of this condition are known (2,3). Patients suffering from this condition are at an increased risk of depression, socially withdrawn and potentially suicidal. Furthermore, patients have even stopped their life saving HAART therapy without consultation with their physician in an attempt to stop this side effect. The implications for viral mutations, increasing viral load and worsening of patients underlying condition requiring more expensive treatments cannot be stressed enough. Treatment of HIV-Associated Lipoatrophy with Sculptra (Poly-L-Lactic Acid) has been shown to improve anxiety and depression scores (4) as well as improve patient's quality of life as measured by visual analogue scale (5). The use of Sculptra is clearly indicated as a reconstructive procedure; that is, repair of abnormal facial structure caused by HIV or its treatment, in order to create a normal appearance.

The safety and efficacy of Sculptra in restoring the normal facial contours of patients suffering from HIV-Associated Facial Lipoatrophy has been evaluated by the US FDA (6). Based on the available scientific evidence (4,5), the FDA granted approval of Sculptra as a restorative medical device for the specific indication of HIV-Associated Facial Lipoatrophy in August 2004.

For your information. the ICD9 diagnosis code for lipodystrophy is 272.6. HIV-related lipodystrophy syndrome consists of lipo-hypertrophy (fat accumulation in the visceral area and dorsocervical pad) and lipoatrophy (subcutaneous fat loss in the face, extremities and buttocks).

Due to the medical necessity of this treatment and the availability of a safe and effective treatment option, pre-approval is hereby requested for treatment of this patient's HIV-Associated Facial Lipoatrophy with Sculptra.

As this approval is relatively recent, I would be happy to further educate your company on this issue in any way that you might deem helpful. Please feel free to contact me at the above office with any questions you may have.

Sincerely,

References:

1) Montessori, V. CMAJ. 2004;170:229-238.

2) James J, Carruthers, A. Dermatol Surg. 2002;28:979-986.

3) Martinez, E. Drug Saf. 2001;24:157-166.

4) Moyle, GJ. HIV Medicine. 2004;5:82-87.

5) Valantin, M. AIDS. 2003;17:2471-2477.

6) FDA Scientific Advisory Panel 3/25/2004 Washington DC