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Medicare approval for ESWT

Posted by tomp on 8/24/04 at 08:42 (158610)

Has anyone been successful in getting Medicare to approve claims for ESWT? According to the Medicare database, ESWT has FDA approval and will be covered when an approved ESWT device is used specifically for the treatment of palatar facitis. However, my doctor does not believe Medicare will approve it.

Re: Medicare approval for ESWT

Tony K on 8/24/04 at 08:52 (158611)

Medicare will pay (Medicare Region A) if the procedure is done in a hospital setting or a Hospital affiliated surgery center. The Hospital fee is $a little under $3000. the surgeon's fee around $300

Re: Medicare approval for ESWT

Ed Davis, DPM on 8/24/04 at 14:48 (158629)

Tony:
That would mean that the hospital or surgicenter would have to have ownership or bring in a machine -- not a treatment model that is seen very often. With rules like that, particularly ones that are in flux, I would not hold my breath waiting to see hospitals getting machines.

Interestingly, other than Ossatron, ESWT does not require a hospital or surgicenter so doing the procedure there would be for 'regulatory' purposes only. Just makes little sense.
Ed

Re: Medicare approval for ESWT

Dr. Z on 8/24/04 at 19:14 (158640)

Tony
What states are in Medicare A Region

Re: Medicare approval for ESWT

Tony K on 8/26/04 at 10:33 (158728)

I don't know every state, but I know WA, ID, OR, CA, WY, and SD are for sure. In South Dakota we've done a number of Medicare cases in the hospitals. The vendors sign agreements with the EWST company where they do all the billing and the hospital pays the vendor. I have not done this in WA, but have in ID.

Re: Medicare approval for ESWT

tomp on 8/30/04 at 09:01 (158954)

Does anyone know if Ohio is in Medicare Region A?

Re: Medicare approval for ESWT

Pauline on 8/30/04 at 15:54 (158997)

If no one can provide you with this answer, I believe you can call the U.S. government phone number listed on their Medicare website and probably get this information.

Re: Medicare approval for ESWT

Ed Davis, DPM on 9/01/04 at 14:49 (159097)

The individual carriers have a certain level of discretion in determining coverage issues. I noted WA listed above so the carrier would be Noridian.
If hospital use is required but no hospital will accept use of its facilities on Medicare patients, we have a catch-22.
Ed

Re: Medicare approval for ESWT

Bill, jr on 9/02/04 at 09:12 (159153)

Dr Ed,

If Medicare is covering at the rate previously posted then I would expect area hospitals to contract with local equipment providers and start offering the service. Hospitals will offer services that are in demand when there is reasonable insurance coverage and physician interest. The current lack of ESWT in a hospital setting is probably the result of the lack of insurance coverage and physician interest.

Re: Medicare approval for ESWT

Dr. Z on 9/02/04 at 09:29 (159154)

Try scheduling any type of elective surgical case at a hospital. Two month back up. That is why there are ASC's

Re: Medicare approval for ESWT

Ed Davis, DPM on 9/04/04 at 16:05 (159325)

Bill:
Noridian, to the best of my understanding will allow one treatment at a total of $300 for the hospital and doctor. This is not clear though.
I cannot see a hospital being able to afford to provide the service at that rate of reimbursement. I have talked to several hospital adminstrators and their response was 'not interested' until some assurance of reasonable payment would be made to them.
Ed

Re: Medicare approval for ESWT

Ed Davis, DPM on 9/04/04 at 16:06 (159327)

My local hospital wants all elective cases to go to their ASC.
Ed