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Author Topic: Medicare coverage of Sculptra and Radiesse fizzles  (Read 25502 times)

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Offline Miss Philicia

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Medicare coverage of Sculptra and Radiesse fizzles
« on: January 26, 2011, 09:21:14 AM »
source: Poz magazine, Jan/Feb issue

Losing Face Filler

by Tim Murphy

Medicare coverage of Sculptra and Radiesse fizzles.

Last March, HIV-positive people with facial lipoatrophy (loss of facial fat caused by HIV or the meds) rejoiced as Medicare announced it would reimburse doctors for injecting the fillers Sculptra and Radiesse. The news, it was hoped, would inspire more doctors to provide the treatment.

But Medicare set treatment reimbursement at a paltry $100 per visit (several are usually required), and most HIV doctors charge about $400 to $500 per visit for the procedure; non-HIV specialists charge up to $900. “The coverage is obviously a disappointment, and I doubt doctors will be flocking to provide this service,” says Gerald Pierone, MD, a Florida HIV doc who does the treatments. Doctors and patients also say regional Medicare contractors have not followed through on reimbursements and don’t seem to understand the new, required coding for them.

One HIV-positive man in Charleston, South Carolina, says Medicare has yet to reimburse  his doctor for “Round 1” of the treatment. “Almost five months after my first session,” he says, “the possibility of additional treatments, which might help me [have] a ‘normal’ appearance, is still up in the air.”

Medicare rep Ellen Griffith insists there was a public comment period before rates were set, but Nelson Vergel, an HIV-positive advocate on the issue in Houston, says, “They never showed us any proposed rates to comment on.” The rates aren’t up for revision until November 2011, but “an onslaught of letters to Medicare [7500 Security Blvd, Baltimore, MD 21244] from patients will help put the ball in motion,” says Doug Mest, MD, an HIV doctor in DC who does the procedures.
In the Meantime…
If your HIV doc doesn’t do the procedures or can’t refer you to one who does—and who accepts Medicare—go to medicare.gov, click “Facilities and Doctors” at left, then “Find a Doctor,” then search with the “Dermatology” specialty.

Once you find a Medicare-accepting doctor who’ll do the treatments, make sure he or she bills Medicare with this info:

1. A date of service (LIDOS) on or after March 23, 2010
2. A line with the HCPCS code Q2026 (Radiesse) or the HCPCS code Q2027 (Sculptra)
3. A line with the HCPCS code G0249 (dermal filler injection procedure)
4. The ICD-9-CM diagnosis codes 042 (HIV) and 272.6 (lipodystrophy)

If you hit a wall, contact Nelson Vergel via facialwasting.org. He’ll be gathering patient testimony to urge Medicare to revise coverage rates. 
"I’ve slept with enough men to know that I’m not gay"

Offline burstnbloom

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Re: Medicare coverage of Sculptra and Radiesse fizzles
« Reply #1 on: January 27, 2011, 07:04:49 PM »
Yes this is so disappointing ..after contacting dozens of providers..they all said they cannot participate any further because the medicare reimbursement does not cover even a slight percentage of the cost of the injections and fillers.  Just another Government let down..but all we can do is keep pushing forward and hope they will come around and pay a better price so these docs will do the procedures so many need.

Offline Joez

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Re: Medicare coverage of Sculptra and Radiesse fizzles
« Reply #2 on: February 05, 2011, 02:23:01 PM »
I went thru the Radiesse thing about 6 yers ago. I spent ~$7000. I looked better for awhile, but the effects dissapated within about  year. The doctor who performed the prcedure suddenly died of a heart attack a couple of years ago. I am now seeing a plasitic surgeon who is injecting silicone in  my face for $800 a pop. I have doen5 treatments. I see somewhat f an improvement but she think I need at least 7 more. I a 50 now and I know these shots are not going to make me look 30 (or even 40). I hope I end up with a good result that I am happy with but I doubt it.

Offline jm1953

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Re: Medicare coverage of Sculptra and Radiesse fizzles
« Reply #3 on: February 05, 2011, 09:41:50 PM »
Thanks Miss P for the update. When it was first announced that Medicare would cover Sculptra, I was on the phone with my insurance company and my dermatologist for two weeks trying to coordinate it.  Nothing ever happened, a complete waste of time, and my dermatologist would never have agreed to Medicare's payback anyway.  We bagged the whole thing and I'm paying out of pocket for the procedure and Sculptra has been helping me with getting my medicine through the PAP.

Hope your last treatment went well.  I'm due for another soon.  My face seems to just absorb the stuff like a sponge.

Thanks too for all your intelligent posting.  You seem very knowledgeable.  And also I appreciate your candor.  Telling it like it is.

Best always,

Positive 29 years. Diagnosed 10/1987.  Current CD 4: 720: Viral load: almost 100.  Current drug regimen, Tivicay, Emtriva, Endurant, Wellbutrin, Clonazepam, Uloric, Losartan Potassium,Allegra, Ambien, Testosterone, Nandrolone, Vicodin, Benedryl, Aspirin, lots of vitamin supplements.

Offline klipsch

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Re: Medicare coverage of Sculptra and Radiesse fizzles
« Reply #4 on: March 09, 2011, 03:41:40 PM »
Just for clarification sake. Are we saying that Medicare is falling short on the doctors fee's...the material, or both?
when shit has value...the poor will be born without assholes...

Offline Jeff G

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Re: Medicare coverage of Sculptra and Radiesse fizzles
« Reply #5 on: March 09, 2011, 03:49:43 PM »
My doctor told me that medicare was not paying enough to cover a fraction of the cost of the fillers .
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Offline denb45

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Re: Medicare coverage of Sculptra and Radiesse fizzles
« Reply #6 on: March 09, 2011, 05:31:13 PM »
My doctor told me that medicare was not paying enough to cover a fraction of the cost of the fillers .

Yeah, I kinda figured it would died on the vine, before anyone could really benefit by it, to bad, what a shame  ???
"it's so nice to be insane, cause no-one ask you to explain" Helen Reddy cc 1974

Offline burstnbloom

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Re: Medicare coverage of Sculptra and Radiesse fizzles
« Reply #7 on: April 12, 2011, 08:05:10 AM »
The link to sign this can be found on Aidsmeds.com under Treatment News....please everyone go and sign and maybe Medicare can be convinced to pay up for what they promised us.

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

April 8, 2011

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.”


Offline aztecan

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  • 32 years positive, 60 years a pain in the butt
Re: Medicare coverage of Sculptra and Radiesse fizzles
« Reply #8 on: April 18, 2011, 02:57:55 PM »
Medicare coverage of this will probably vanish in the coming year.

It is unfortunate, but I fear we will be looking at health services being prioritized in coming years and, with nearly 8,000 people in the U.S. on waiting lists just to get HIV meds, it is pretty much a given that ancillary assistance such as facial fillers will be a lesser priority.

I know ADAP is a separate issue, but your friendly Republican haymakers are looking to cut anyting they can get away with, including Medicare or funding for ADAP.


« Last Edit: April 18, 2011, 03:01:43 PM by aztecan »
"May your life preach more loudly than your lips."
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Offline Mmmikey

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  • Posts: 2
Re: Medicare coverage of Sculptra and Radiesse -- response to Klipsh
« Reply #9 on: May 02, 2011, 08:42:19 PM »
In response to Klipsch:
Each separate region of CMS, which administers M'care and M'caid, has set a different reimbursement rate.  In almost all cases, the reimbursement rates BOTH fail to cover the cost of the filler material AND set the procedure payments so low it doesn't cover office expenses.  As a result no practice can realistically afford to provide the service... in addition to taking a beating on the cost of the material & procedure, Medicare's convoluted billing regulations would require participating practices to under-charge even for non-M'care patients.  The whole business has become a sad disaster.  Not only is no-one willing or able to provide the service at these rates, but the manufacturer's PAP (Patient Assistance Programs) will no longer provide product to anyone who has M'care coverage.  So we are royally screwed. 

Offline Oceanbeach

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Re: Medicare coverage of Sculptra and Radiesse fizzles
« Reply #10 on: March 25, 2012, 05:33:14 PM »
I see, all this happened last year while I was getting my first injections of Sculptra and had no internet, for the year.  I do remember a series of TV commercials for Sculptra targeting beautiful women.  Thought they were going after the Juvederm customer.   ;D  Have the best day


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