Insurance denies IVIG Treatment for transplants!

Discussions for Patients, Family, and Friends HD For Patients
1

Necessary Expansion of IVIG Treatment under Medicare

This firm represents the transplant surgeons at the Indiana University Hospital and the surgeons desire that a particular Medicare contractor expand its coverage of intravenous immunoglobulin (IVIG) treatment.

Wisconsin Physicians Service Insurance Corporation (WPS) is a Medicare Administrative Contractor (MAC) for Jurisdiction 5 and Jurisdiction 8 (Iowa, Kansas, Missouri, Nebraska, Indiana and Michigan), as well as a Legacy Medicare Part B contractor for Wisconsin, Illinois, and Minnesota. According to its website, WPS “serves more than 175,000 providers and 9.5 million Medicare beneficiaries” and “processes more than 160 million claims with benefit payments of more than $50 billion annually.” However, WPS has decided not to cover IVIG treatment under Medicare for the desensitization of kidney transplant patients. WPS made this decision despite the presence of significant and overwhelming medical evidence that demonstrates IVIG treatment effectively and efficiently ensures that highly sensitized patients can have successful transplants.

Approximately 30% kidney transplant patients require desensitization in order to receive a transplant. Patients may need desensitization because of childbirth, previous transfusions or previous transplants. IVIG treatment has been proven to successfully desensitize such patients, lengthening life spans and reducing systemic medical expenditures.

In light of the persuasive medical evidence, other Medicare contractors have decided to cover IVIG treatment for the desensitization of transplant patients. In local coverage determinations (LCD), National Government Services, Inc., (A47381/LCD 25820), Palmetto GBA (LCD 25820), and Cahaba GBA (LCD 30029) have all codified IVIG as a covered Medicare treatment for the desensitization of transplant patients.

In its LCD 30147, WPS covers IVIG treatment for thirty conditions, however, none apply to highly sensitive transplant patients/recipients. Thus, the goal is to have WPS include the following language, or something similar, in LCD 30147:
Sensitized renal transplant recipients: IVIG and/or plasmapheresis are used in several sequential treatments pre or post transplant to help with patients sensitized to living or cadaveric organ donors. The attempts to modify panel reactive antibody and/or donor specific antibody levels, with prevention and/or treatment of organ rejection.

Besides presenting WPS with medical evidence demonstrating the need to have IVIG treatment for highly-sensitized transplant patients, we were hoping to compile information regarding all the Medicare contractors that cover such treatment. With this knowledge, we will also learn where (geographically) in the country this treatment is covered under Medicare. Unfortunately, this information has been rather difficult to track down and, thus, we are contacting you and your organization for assistance.
In addition to this research, we would like to organize and sponsor an informal gathering/lunch among the professionals and experts to discuss the best approaches for how this treatment can be fully covered under Medicare, and therefore dismantle the piecemeal approach currently plaguing the healthcare system. We aim to develop a strategy to implement on Capitol Hill that will ensure highly sensitized patients have an affordable avenue to receive IVIG treatment.

If you can help with our request or would like to attend the informal gathering as described above, please call Bill Broydrick or Brendan Lowd at 202-637-0637, or feel free to email Bill at billb@broydrick.com, or Brendan at brendanl@broydrick.com.

Thank you for your assistance with this matter.

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You might want to read this Anthem Blue Cross Blue Shield memo (page 2) where it says “IVIg is also considered medically necessary for the following off-label indications:…Prior to a medically necessary renal transplantation for suppression of panel reactive anti-HLA antibodies in individuals with high panel reactive antibody (PRA) levels to human leukocyte antigens (HLA).” The document has a list of journal articles 4 of which refer to transplant.
http://www.advocacyforpatients.org/pdf/gbs/gbs_anthem_policy.pdf

This article led me to the organization that posted this policy. The link below says the FDA has approved IVIg for “kidney transplant with a high antibody recipient or with an ABO incompatible donor,” but I haven’t been able to find the approval on the FDA site. This organization may be tracking who pays for IVIg and may be able to help you advocate for coverage.

There is a National Coverage Determination database on the CMS website. If you use the search term “IVIg” you’ll see a long list of Medicare payers that have a policy about IVIg.
http://www.cms.gov/medicare-coverage-database/overview-and-quick-search.aspx

3

Beth,
Thanks! I’m looking things over. I wondering if these insurance people think this IVIG treatment is experimental - I’m hoping these aren’t the sort of insurance people who think the earth is flat (round? just crazy, wild-eyed theory talk).

4

Just read this article about advocacy efforts by transplant programs at the University of Michigan and the University of Indiana with the Medicare contractor WPS.

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[QUOTE=Beth Witten MSW ACSW;22669]Just read this article about advocacy efforts by transplant programs at the University of Michigan and the University of Indiana with the Medicare contractor WPS.
http://www.jsonline.com/business/diabetics-tied-up-as-medicare-contractors-split-on-kidney-treatment-807u0vj-184772511.html[/QUOTE]

They must hate saving money, idiots. The actions of some of these people in this field continue to amaze me.

6

Wisconsin Physicians Service reverses decision on kidney treatment coverage.

[I]The unit of Wisconsin Physicians Service Insurance Corp. that handles Medicare claims will cover a treatment that can increase the chances of dialysis patients’ finding a suitable match for a kidney transplant.

The decision partially reverses a decision last year that was challenged by doctors at the University of Michigan and Indiana University.

The treatment - intravenous immune globulin, or IVIG - can lower the level of antibodies that increase the risk of a patient rejecting a donor kidney.

WPS, based in Madison, had determined that the treatment was experimental and therefore not covered by Medicare.

The cost of the treatment is borne by Medicare, and WPS did not have a financial stake in its decision.

Medicare covers dialysis patients after four months or, if they have insurance, after 30 months.

Several transplant centers stopped providing the specific type of treatment - high-dose IVIG - used by the doctors at the University of Michigan and Indiana University, and some doctors and studies question the treatment’s effectiveness.

But after reviewing studies on the treatment as well as talking to Stanley Jordan, medical director of the kidney transplant program at Cedars-Sinai Medical Center and one of the pioneers in the treatment, the company decided to cover the treatment for some patients who are candidates for a transplant, according to a letter sent to the University of Michigan on Friday.

Decisions about whether Medicare should cover such treatments are left to regional contractors that process Medicare claims, what is known as a local coverage determination.

Medicare covers the kidney treatment in some parts of the country, and the previous contractor for Michigan and Indiana had covered the treatment. That changed last summer when the contract for the two states went to WPS.

Roughly one-third of people waiting for kidney transplants have antibodies as a result of blood transfusions, previous transplants or pregnancies that increase the risk of their body rejecting a donor kidney.

The IVIG treatment only works for some patients.

For instance, the treatment works in less than one-third of the patients at Indiana University, Tim Taber, a professor and medical director of transplant nephrology, estimated late last year.

“It’s not a home run,” he said at the time. “But it’s one of the few things you can do for patients.”

Tabor and Miagros “Millie” Samaniego, medical director of the University of Michigan kidney transplant program, could not be reached late Monday.

WPS processed 168.3 million claims and oversaw payments of more than $39.5 billion for more than 10 million people covered by Medicare in its last fiscal year.

WPS declined to comment beyond the letter it sent to the University of Michigan.

The company will cover the treatment only for patients with antibodies below a specific threshold - those with scores below 80% on panel reactive antibody tests.[/I]