| Lost password
751 users onlineYou are not loggend in.  Login
Xiaflex battles with Insurance
 1 2 3
 1 2 3
04/21/2011 20:08
flojo 
04/21/2011 20:08
flojo 
Re: Xiaflex battles with Insurance

@ JBY123,

The Clinical Guide for Collaganese was very helpful. Good to see the terminology they use.

Do you have a link to Anthem Blue Cross's Clinical Guide for Radiation Therapy for Dupuytren's? I'm not able to search their site and find it. It will be useful to me.

Thanks,

Flora

04/22/2011 15:32
photobill

not registered

04/22/2011 15:32
photobill

not registered

Re: Xiaflex battles with Insurance

Sorry Flora, I don't. I'm new to this and am just gathering information to do battle with

Anthem BC/BS over non payment of a xiaflex treatment.

Bill

05/05/2011 01:19
marla1955 
05/05/2011 01:19
marla1955 
Re: Xiaflex battles with Insurance

Hi,
I am writing on behalf of my husband who is in the process of receiving Xiaflex injections in his left hand to take care of DC in pinkie and then his ring finger. He had the first injection and stretching on 4/26 and 27th. It is amazing to witness his pinkie finger's range of motion at the base of his finger and palm improve with the splinting and exercises an OT has done and recommended!!!

However, we are battling our local insurance company about reimbursement for the injections performed by the doctor, the finger manipulation and the splinting. His prescription drug coverage thru his employer has a specialty drug pharmacy and Xiaflex has been on their approved list for about 9 months. So yes the major expense of the drug is covered for us. The insurance company has declined twice to reimburse anything with the procedure because they consider it expermental and not enough medical evidence to support Xiaflex use. My husband is a diabetic and had a low blood sugar incident last spring which has affected his short term memory. The diagnosis of Dupuytren's came during his four day stay in the hospital because at first they thought he had had a stroke and their was neurological damage and that is why his two fingers were contracted.

So at this point our doctor is assisting us with filing an appeal with the NY State Insurance Department. Xiaflex is available, it is not an experimental drug any longer. It IS a new drug which seems to work miracles and why any insurance company would not support it is beyond me. To everyone out there struggling with their insurance company keep filing appeals and if all else fails go to your state insurance department and file an external appeal. Medicare has recently created a code for the treatment of Dupuytren's with Xiaflex from what we were told. If my husband was 9 years older he could get the treatement thru Medicare. However, his contractures won't let him wait. If you need information on the clinical trials etc go to the Xiaflex website and if you are not into computers get their toll free number and call. I called before we knew the drug would be covered with prescription insurance and the two people I spoke to were patient and understanding and sent me an abundance of information thru the mail. Hang in there and do not give up!

Edited 05/05/11 04:21

05/10/2011 20:37
DCinNYC 
05/10/2011 20:37
DCinNYC 
Re: Xiaflex battles with Insurance

The Healthwell Foundation (http://www.healthwellfoundation.org) is set up to assist with the costs of Xiaflex. You will have to check with them for the specifics of benefits since there are qualifications based on what your insurance covers.

05/10/2011 21:32
marla1955 
05/10/2011 21:32
marla1955 
Re: Xiaflex battles with Insurance

Thanks DC I will look into it!

06/24/2014 21:03
jdphoto 
06/24/2014 21:03
jdphoto 
Re: Xiaflex battles with Insurance

Photobill:
I had a Xiaflex treatment on my right hand this past December. The results have been terrific. I had thought going into the procedure that it would be covered by Anthem BC/BS of NH. I had waited about 6 mos. for the approval process to get the serum. Once approved, the serum was shipped from the pharmacy to my hand doc and I had the injections one day and the manipulation/straightening the next. Two months later I get notification from BC/BS that they would not cover the manipulation portion of the bill stating that the procedure was "experimental/investigational" and they did not provide benefits for that. Thus, a month later I received a bill for $1300+ for the "manipulation, finger Joint Under Antheshesia" Insurance covered the cost of the drug, the injection, and the splint, but was denied because the manipulation portion of the therapy is considered in their manual to be investigational and/or experimental. They wrote "We have determined that: No demonstrated evidence exists to determine that the service is not experimental."

I appealed and was denied a second time. I talked to an agent of the insurance company again yesterday and she pointed out that the cost of the drug was covered because the prescription portion of my insurance is different from BC/BS and that they covered the actual injection because they cover all injections and it had nothing to do with it being a treatment for DP. They also covered the cost of the splint.

She said I could appeal a second time but before I do, I would like to know the experience others have had in getting insurance companies to recognize and provide benefits for this procedure and what arguments or evidence I can provide to show that this is an FDA approved procedure that works, is less invasive and cheaper than surgery, and is not still in its testing or experimental phase.

I'm happy to report that 4 months out, I have full extension of my right hand, no sign of recurrence, and it feels as good as new. My left hand has some nodules but little contraction yet. When and if the time comes for my left hand to be treated, I will opt for surgery because insurance will pay for that unless I can get some satisfaction in my present case.

Does anyone have any ideas on how to fight for insurance coverage?

Thanks.
Billk
Amherst, NH
Xiaflex (collagenase clostridium histolyticum) was approved by the FDA effective February 22, 2010. It is indicated for the treatment of adult patients with Dupuytren's contracture with a palpable cord.

Because there are very serious risks involved with the administration of Xiaflex, NAS has determined that this drug will only be covered if the patient is believed, by the provider, to not be a candidate for surgical treatment of the Dupuytren's deformity. Judgment regarding this decision must be clearly documented in the patient's medical record. Reimbursement for this drug is 106% of the Wholesale Acquisition Cost (WAC), or as updated by CMS.

The following conditions apply:
22 Only payable diagnosis - ICD-9-CM 728.6, contracture of palmar fascia (Dupuytren's contracture)
22 Medical record must include documentation indicating the reason(s) the patient is deemed unable to tolerate surgical form of treatment.
22 Provider must be enrolled as a qualified healthcare provider by the manufacturer. (Refer to the complete Prescribing information, and Training and Safety information at http://www.xiaflex.com/ )
22 To be consistent with the FDA labeling information, the patient must be seen 24 hours after injection
* If necessary, the injection and follow-up visit may be repeated up to 2 times at 4-week intervals. (Per the FDA approved drug label "Injections and finger extension procedures may be administered up to 3 times per cord at approximately 4-week intervals.")
22 Inject only one cord at a time. If the patient has other cords with contractures, inject each cord in sequential order.

Billing instructions:
22 Bill - CPT 20550, injection(s) single tendon sheath, or ligament, aponeurosis (eg, planter "fascia")
* NAS does not expect a separate Evaluation and Management (E&M) service to be billed for that date
22 Bill Xiaflex with J3490, until a permanent HCPCS code is assigned
22 Include drug name and dosage in Item 19 of the CMS-1500 claim form or its electronic equivalent
22 Office visit 24 hours after the injection:
* Bill applicable E&M and document encounter accordingly
* Bill 29130, application of finger splint; static
* Bill Q4049 (Finger splint, static) for the finger splint. Put the
name and price of the splint (include shipping but NOT handling costs)
in Item 19 of the CMS-1500 claim form or its electronic equivalent

Effective for dates of service on and after February 22, 2010.

Bill Codes:

11 - Hospital Inpatient (Including Medicare Part A)

06/24/2014 22:21
moondanc 
06/24/2014 22:21
moondanc 
Re: Xiaflex battles with Insurance

Not sure why this old thread popped up again. Here's a link to Aetna which is very thorough and has lots of info to use for communicating with insurance companies.

http://www.aetna.com/cpb/medical/data/800_899/0800.html

Xiaflex also has a "co-pay" program that will help with costs. They also say 99% of patients are covered by insurance--whether this is true or not...
https://www.xiaflex.com/dupuytrens-contr...&print=true

https://www.xiaflex.com/dupuytrens-contr...&print=true

Xiaflex is also covered by Medicare and that is generally the gold standard as to whether a medication is "experimental" or not.

That said--stay away from Xiaflex if you can possibly help it. Way too many instances of it exacerbating the disease as fast or faster than other interventions.

07/23/2014 22:37
econn 
07/23/2014 22:37
econn 
Re: Xiaflex battles with Insurance

Since this old thread has been resurrected, I will add a few new comments. I just received confirmation that HealthWell Foundation will cover all the cost of Xiaflex with a grant. Apparently the Xiaflex voucher doesn't work with Medicare supplement insurance. I am scheduled for injection tomorrow (Thur, July 24th) and back for manip the next day. I'll post my experience with this procedure when everything settles down and I can see the results.

07/28/2014 23:53
Brian_PDX 
07/28/2014 23:53
Brian_PDX 
Re: Xiaflex battles with Insurance

Go to Auxilium, the manufacturer of Xiaflex, as they have a unit that does nothing but help with appeals. I was successful with their help but I have had extensive legal experience and have appealed many issues in government and private industries successfully. Insurance companies try and call Xiaflex experimental or limit treatments due to cost so use the research data Auxilium has, note the progressive nature of the disease, your personal success with Xiaflex, the cost of palmar fasciectomies, disability, legal process, humanitarian issues and note you will go to your state's insurance commissioner. Copy the insurance commissioner. This is war. Good luck.

07/30/2014 23:33
littlepeaks 
07/30/2014 23:33
littlepeaks 
Re: Xiaflex battles with Insurance

This is OT -- been thinking a lot about insurance coverage. Would be nice if the Dupuytrens Foundation could produce a compilation of major medical insurance companies, and their caveats for paying for the various DD treatment options (especially RT and Xiaflex) -- and the state of DD condition required for approval (ie -- in an active state, degree of contracture, etc. I had Xiaflex treatment in February, and Medicare Part B and Tricare for Life paid all my medical expenses.

 1 2 3
 1 2 3
investigational   treatment   because   dupuytrenfoundation   battles   healthwellfoundation   information   procedure   Insurance   Foundation   dupuytrens-contr   injection   experimental   insurance--whether   Xiaflex   Dupuytren   manipulation   covered   company   approval