Farrow wraps

[morgantownmom]

I have had lymphedema as long as I can remember in my legs and I am 59 yrs old.My husband was taught how to wrap my legs but I would love more independence and the farrow wraps would do the trick. You thought correctly if you think insurance will not cover them. The reason being the maker does not even have a billing code for ANY insurance company or medicare. I have medical problems that make it impossible to pull on compression stockings. I do have Reid sleeves and love them and my insurance did pay for them as well as medicare. The other plus with the Farrow Wraps would be enabling me to take a shower every day rather than 2 or 3 times a week. What can we do to get the Farrow Wraps covered by insurance. A person would need 3 sets per leg and if you need both sets and pay 20% co-pay with insurance would still cost over $600 and without insurance several thousand. H E L P :confused:

[Trish]

I can easily understand why you are confused about this issue. I've discovered that the best way to learn is to ask questions. The Farrow web site address, as listed in the Lymph Notes Resource Directory, is www.FarrowMedical.www

So my suggestion is that you go to their web site, find "Contact us," and make contact. Then start asking questions! Most companies have someone on staff to help with insurance issues.

I've been through this sort of battle several times (different companies) and I find it helps to remember that many of the confusing issues are due to insurance company issues but you need to be your own advocate.

Here's to a successful outcome!

Trish

[morgantownmom]

I called and spoke to the co-maker of Farrow Wraps. He had no clue how to go about getting a billing code so gave me to another person on the team. She in turn had no clue about billing codes and after our conversation she is going to look into how to go about getting a billing code for insurance. In the past they have billed the fitting co. who in turn bills the patient and thought the fitting co. probably took care of insurance. I explained I know a lot of people who would love to have the Farrow Wraps but cannot afford them. With an insurance billing code the manufacturer could sell many more Farrow Wraps and she then realized getting an insurance code could be quite lucrative for them. She has my number and if she can get the billing code will contact me.

[Trish]

So you did "all of the right things" and didn't get a good answer. Aside from being very disappointed, and angry, there are two more things I would do.

(1) I would contact Robert Weiss at LymphActivist@aol.com He is very knowledgeable about this sort of issue. He is also wonderfully helpful and probably can help you with this problem.

(2) I would send an e-mail to Dr. Wade Farrow, the developer of the Farrow wrap, and explain your experience with a lack of service. Maybe I'm wrong, but when things go wrong in this way, I believe he would be happy to get feedback so he can correct the problem.

Good luck in getting a good answer this time.

Trish

[bcreighton]

Ladies,

To your concerns regarding insurance reimbursement and HCPCS code assignment for FarrowWraps...

We are aware of the inability of some of our patients to afford a FarrowWrap.

HCPCS Code Assignment
The process of first getting a HCPCS code and then insurance reimbursement is not a simple or inexpensive matter. To be done properly, it is quite complicated, nothwithstanding I'm sure some may say to the contrary. But, there is a difference between the plain application process and properly approaching an application.

Once application has been made, it is the government that decides which, if any, HCPCS code will be assigned; and, after review of previous applications by other companies, I'm not sure the result is always equitable.

Patients want quality products inexpensively. However, if Medicare, say as ONLY an example, reimbursed $10 for a compression garment, then there would be VERY few options from which a patient could choose, and few to none of any quality or efficacy. This would limit patient choice and product innovation. On the other hand, if Medicare reimbursed $10,000 for a garment, that would obviously foster a wasteful environment squandering valuable Medicare resources. If Medicare reimburses at varying levels, how is a decision to be made what they will reimburse for what that will be fair now to everyone and not hinder innovation in the future?

After review of the situation, I believe I would like to see Medicare adopt a stance for compression garments similar to how they have recently handled a new type of lens implant for cataract replacement surgery, which opinion has been expressed to Bob Weiss.

A brief synopsis of the Lens Implant ruling as I presently understand it: Medicare only reimbursed so much for an IOL, intraocular lens, for use after cataract surgery. Unfortunately, time has gone by, technologies have improved, and the standard IOL was not fully suited to all patients, ie patients with severe astigmatism.

A company developed a better lens for this patient population, but expressed that it could not afford to bring it to market for what Medicare would reimburse. As a consequence, they requested that Medicare allow patients to pay the difference between what Medicare would reimburse and the actual cost of the lens. Medicare apparently consented and issued a ruling, "Astigmatism-Correcting Intraocular Lens—CMS 1536 Ruling."
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Astigmatism-Correcting Intraocular Lens—Implementation of CMS 1536 Ruling
CMS has issued the following MLN Matters article. Information for Medicare Fee-for-Service Health Care Professionals.

Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, fiscal intermediaries [FIs], or Part A/B Medicare administrative contractors [A/B MACs]) for services provided to Medicare beneficiaries.

Provider Action Needed
This article is based on change request (CR) 5527, which discusses a recent administrator ruling from the Centers for Medicare & Medicaid Services (CMS) regarding astigmatism-correcting intraocular lenses (A-C IOLs) following cataract surgery (CMS-1536-R). The new policy is effective for dates of service on and after January 22, 2007. Physicians and
providers need to be aware that effective January 22, 2007:
• Medicare will pay the same amount for cataract extraction with A-C IOL insertion that it pays for cataract extraction with conventional IOL insertion.
• The beneficiary is responsible for payment of that portion of the hospital or ambulatory surgery center (ASC) charge for the procedure that exceeds the facility’s usual charge for cataract extraction and insertion of a conventional IOL following cataract surgery, as well as any fees that exceed the physician’s usual charge to perform a cataract extraction
with insertion of a conventional IOL...
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Now patients have better choices, innovation is fostered, patients can still opt for the regular IOL, and a simple and non wasteful payment strategy was maintained.

At this time, I believe I would like to see Medicare adopt such a ruling for compression garments. Otherwise, companies with good quality compression garments could be adversely affected and patient options unduly hindered.

Other Options
Next, please note the creation of the Marilyn Westbrook fund, which FMI has helped fund: http://www.lymphnet.org/patients/westbrookFund.htm

This organization will help fund garments for patients with lymphedema that cannot afford them. For those able, a donation would be greatly appreciated.

In addition, some private insurance companies do reimburse for our garment. You can try to work with whoever is providing our garment to see if they can file the paperwork or call us for assistance finding a company, although we can make no guarantees.

Finally, if you are truly in need of a FarrowWrap and cannot afford one and have exhausted other avenues, you could request to have your DME, or who ever is supplying our garment, make a request for help on your behalf for our consideration. Obviously, we, or our partners, cannot provide free garments to everyone, but we do want to work with our business partners to help those in need willing to do what they can.

Aside from this, I can only tell you that we are aware of the situation and are working on resolution. Please note that we have only been in business a few years. Also, please note that our product is entirely manufactured in the US by US citizens.

Kind regards,

Farrow Medical

[LymphActivist]

Re: Medicare reimbursement for FarrowWraps:

I have a number of Medicare appeals going now for FarrowWraps, and offer the following comments:

Always purchase a compression garment from a "Medicare-enrolled Supplier". Their names are listed on the Medicare website:

http://www.medicare.gov/Supplier/Include/DataSection/Questions/SearchCriteria.asp?

They are required by law to file a claim for you even if they know/think the item is not covered. Ask them to use "an L-Code" to get the claim going, since the item fits the definition of a "prosthetic device" which may be covered by Medicare.

When the claim is denied, contact me and I'll help you with an appeal. The appeal will take about 2 years to process through the appeal system, and you will have a better than even chance of receiving a reimbursement.

So you might ask "why bother?"

Well, Medicare has no way of knowing whether there is a problem unless and until the number of complaints reach a certain level. We've had 15 denial reversals so far from 8 different Administrative Law Judges, and Medicare is starting to notice.

There is a meeting scheduled for next month where Medicare is asking for evidence that the modalities of lymphedema treatment are effective. I have been trying to get them to recognize this problem for 10 years to no avail. We're starting to be heard.

It is up to you, the lymphedema patient, to file a claim for EVERY bandage set, compression stocking, custom compression garment that is denied, and fight the denial to whatever level necessary. These appeals do not cost you anything except for the copying and postage costs, and if I am doing your appeal I pay for those.

So let's get those claims going!

Bob Weiss "LymphActivist"
Lymphedema Patient Advocate
National Lymphedema Network

[LymphActivist]

I called and spoke to the co-maker of Farrow Wraps. He had no clue how to go about getting a billing code so gave me to another person on the team. She in turn had no clue about billing codes and after our conversation she is going to look into how to go about getting a billing code for insurance. In the past they have billed the fitting co. who in turn bills the patient and thought the fitting co. probably took care of insurance. I explained I know a lot of people who would love to have the Farrow Wraps but cannot afford them. With an insurance billing code the manufacturer could sell many more Farrow Wraps and she then realized getting an insurance code could be quite lucrative for them. She has my number and if she can get the billing code will contact me.

Hi Morgantown Mom,

There are a number of separate issues here. One is whether the item is covered by Medicare or the Insurance company. Another issue is whether the the "correct" code is used to do the billing. And the third issue is how to get a billing code that is fair for the manufacturer. I'll make some comments on each of these issues.

Is the Farrow Wrap covered by Medicare? Unless it is used as a secondary dressing in the treatment of an open venous ulcer, it is not covered. I have made the argument in many Medicare appeals that when it is used in the compression therapy of lymphedema, it meets the definition of a "prosthetic device". I have had 21 agreements to this argument by 10 Administrative Law Judges. Unfortunately each case must be argued through 3-4 levels of appeal and the reimbursements are made over two years after the Beneficiary pays for the garment.

What is the "correct" billing code for a Farrow Wrap? Since the Farrow Wrap is only covered if used to treat an open venous ulcer, it is classified as a "secondary surgical dressing". The Farrow Wrap resembles a product made by another manufacturer which is billed as an "A6545 Gradient Compression Wrap, Non-Elastic, Below Knee, 30-50 mmHg" but the FarrowWrap has not been approved for reimbursement under this code. Perhaps it is because the reimbursement for this item is $85.00.

A recent change (effective 1/1/2010) in coding clarifies this issue:

"As part of this update CMS is adding the AW modifier to the fee schedule file for HCPCS code A6545 Gradient Compression Wrap, Non-Elastic, Below Knee, 30-50 MM HG, Each. Code A6545 is covered when it is used in the treatment of an open venous stasis ulcer. Currently, code A6545 is noncovered for the following conditions:
o
Venous insufficiency without stasis ulcers, prevention of stasis ulcers, prevention of the reoccurrence of stasis ulcers that have healed, and treatment of lymphedema in the absence of ulcers. In these situations, since an ulcer is not present, the gradient compression wraps do not meet the definition of a surgical dressing. Suppliers are advised that when the non-elastic gradient compression wrap code A6545 is used in the treatment of an open venous stasis ulcer, it must be billed with the AW modifier. Claims for code A6545 that do not meet the covered indications should be billed without the AW modifier and as such, will be denied as non-covered."

Perhaps a better approach would be to code the product to match the description of its function in compression therapy of lymphedema. There is a code A6549 Gradient Compression Stocking/Sleeve, Not Otherwise Specified" that is a collection of items including custom gradient compression stocking and lymphedema gradient compression stocking. Since this code includes a number of differently-priced items, there is not a fixed reimbursement for this code. The reimbursement would be determined by the local DME MAC based in part on the selling price. EXCEPT that this code is not covered as it does not meet the coverage requirements of surgical dressings, splints and braces or durable medical equipment. It has not been tested against the coverage criteria for "prosthetic devices". That is what I am doing when I help Medicare Beneficiaries appeal their cases.

How does a Manufacturer get a Billing Code Number? There is an established process for a manufacturer to obtain a HCPCS Code for his product. The process takes about a year with the HCPCS WorkGroup, followed by an equal period to have the reimbursement amount determined by another agency (PDAC) within Medicare.

A couple of years ago I went through the process and attempted to get billing numbers for a full range of bandages, garments and devices used to treat lymphedema. I requested about 150 L-Codes in recognition that these materials met the definition of "prosthetic devices" which took an L-Code and not an A-Code for surgical dressings. The code definitions I provided were narrow enough that fair reimbursements could be established for "like" items. I was unsuccessful and was told that there was no need for any new codes, that there have been no complaints from any provider, supplier or manufacturer, and that I had no standing to apply for codes since I could not supply manufacturing and cost and production information since I was not a manufacturer.

The process costs very little except for the time to collect the data, submit a 40-page request form and make an appearance in Baltimore to argue the case. I had no support from any manufacturer although I contacted every large bandage and garment manufacturer.

Maybe with enough pressure from patients on the manufacturers, insurers, suppliers and therapists we can effect a change in policy.

LymphActivist