Cynthia Matossian, MD, FACS, ABES, takes a look at the recent, sudden change in low-payment reimbursement by Medicare Administrative Contractors for LipFlow and MGD procedure codes.
Editor's note: The views expressed in this blog are those of their respective contributor and do not represent the views of Ophthalmology Times® or MJH Life Sciences.
Those of us ophthalmologists who
treat ocular surface disease are accustomed to the fact that most of the in-office procedures available for the treatment of MGD, such as iLux (Alcon), intense pulsed laser or IPL, LipiFlow (Johnson & Johnson), and TearCare (Sight Sciences), are generally not covered by insurance or Medicare.
So, we were all pretty surprised when several of the MACs (Medicare Administrative Contractors), the companies that administer the Medicare program in each region, recently published fee schedules that included a payment rate for 0207T, the temporary Category III or “T code” for LipiFlow.
Worse yet, the published amount — while it varies by — is so low that, in some instances, it doesn’t even cover one-third of the cost of the activators, much less the staff and physician time involved.
Related: Scattered routines have ocular surface consequences
In some cases, other MGD procedure codes were bucketed in the same low payment rate.
The most important thing to know is that this sudden change doesn’t actually mean that Medicare is covering MGD in-office treatments.
In the past, the MACs made blanket decisions that MGD treatments and hundreds of other T codes were not covered, and they automatically rejected any claims submitted under those T codes.
But a federal law passed in 2020, the 21st Century Cares Act, prohibits the MACs from making blanket non-coverage decisions.
Instead, they are supposed to consider each claim on its own merits. In response, some MACs added the T codes to their fee schedule.
Related: The MGD patient journey: maintenance over time
What they did not do was issue a local coverage decisions (LCD).
Basically, they said, “If we decide to cover this procedure, here’s what we’ll pay for it.”
To date, no MAC has issued an LCD for LipiFlow or any other MGD treatment, and none of the manufacturers, to my knowledge, is seeking a permanent code or LCD.
Johnson & Johnson Vision issued a letter stating that they are challenging the published payment rates and helping to appeal any claims that have been paid at that rate.
Thus far, only a handful of claims have been covered and paid.
Call 855-877-3462 or email if this happens to you.
Related: Determining where thermal pulsation + IPL therapy meet
Right now, with no LCD for LipiFlow, there is little reason to be concerned.
But as someone who cares about my patients and wants effective in-office MGD therapies to continue to be available to them, I have personally written to my local MAC to let them know that the published fee is inadequate.
In my next blog post, I’ll address how to be a good advocate in your region.
Read more by Dr. Matossian
March 10, 2022
Kala Pharmaceuticals, Inc., a commercial-stage biopharmaceutical company, announced that UnitedHealthcare has added EYSUVIS (loteprednol etabonate ophthalmic suspension) 0.25%as a covered brand on its commercial formularies effective March 2022.
Kala also announced that Cigna Medicare has added EYSUVIS as a preferred brand effective February 2022. EYSUVIS now has Medicare preferred coverage for select plans with Express Scripts, Prime Therapeutics and Cigna.
“Today’s announcement marks significant progress toward our goal of expanding access to EYSUVIS for the millions of people who suffer from dry eye disease, including dry eye flares,” said Todd Bazemore, president and chief operating officer of Kala Pharmaceuticals. “We look forward to continuing to engage with other commercial and Medicare Part D health plans as we execute on our goal of providing broad market access to EYSUVIS for eyecare professionals and their patients.”
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EYSUVIS became commercially available in January 2021 as an FDA-approved medicine for the short-term (up to two weeks) treatment of the signs and symptoms of dry eye disease.
For full prescribing information, visit www.eysuvis.com.
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