Letter from Massachusetts, requesting HCPCS code for medicinal maggots

Another letter to CMS, requesting reimbursement coding for maggot therapy and medicinal maggots -

Medicaid HCPCS Coordinator
Centers for Medicare & Medicaid Services
Mail Stop S2-01-16
7500 Security Boulevard
Baltimore, MD 21244-1850

Dear Medicaid HCPCS Coordinator:

I am a Registered Nurse who has worked in wound care facilities for 10 years. I have tried to obtain maggot therapy for many of my patients who failed IV antibiotics and conventional debridements, but because there is no assigned HCPCS code for this product and therefore no reimbursement available, this therapy has been unobtainable for clients who would benefit from treatment.

This lack of availability has led to higher cost for inpatient surgical debridements and greater length of stay in hospitals.

I feel that maggot therapy would be a lower cost choice and should be available for use and reimbursement to these clients who need this particular therapy.

Thank you for your consideration in this matter.

Nurse F, Massachusetts

In an addendum, she added:

I have tried to obtain maggot therapy for many of my patients who failed IV antibiotics and conventional debridements, but because there is no assigned HCPCS code for this product . . . this therapy has been unobtainable . . . . because we could not be reimbursed for them, it was stopped . . . . This . . . has led to higher cost for inpatient surgical debridements and greater length of stay in hospitals.

Letter to CMS from Michigan

We received many letters to present to CMS, explaining why reimbursement coding for maggot therapy is so important. I will post a few over the next several days. They speak for themselves, for the authors, and for the biotherapy community at large.

Dear Sirs:

While I can not be physically present at your meeting, I would like to comment via this email on Medicare coverage of medical maggot therapy. I treat diabetic ulcers on a daily basis in my podiatric medical practice. It is heartbreaking to see the loss of limbs and lifestyle changes my patients must undergo. Personally I have treated some of the worst of these patients with medical maggots and gotten very gratifying results. Unfortunately, this therapy is not covered by their insurance and the patient must bear this financial burden. The people that find themselves in this position are usually the least able to afford it. This means they are denied a treatment that could potentially save their limb. I have seen both sides of this: the saved limb by maggots and the lost limb because the patient could not afford the maggots. It is imperative that Medicare develop a code for medical maggot therapy.

Sincerely,
Dr. D, Michigan

Why blog about Maggot Therapy and BioTherapy?

I never thought that I would be blogging, but today I was moved to set up this site about maggot therapy, leech therapy, and other forms of biotherapy. Why? Because I encountered another obstacle to health care. And I am frustrated.

For the past 25 years I have studied and shared the health benefits of maggot debridement (fly larvae that remove all of the dead or gangrenous tissue from a wound without harming the healthy tissue). We made it past the ethics committees, and through the years of minimal research funding. We taught therapists how to use the maggots, despite having to work outside of the conventional Medical School curriculum. In 2002, the FDA was called in to regulate our work, and by 2004 we came out of the experience with marketing clearance!

You would think (or at least I thought) that with FDA marketing clearance any doctor could now prescribe maggot therapy. Legally, they can. But in practice, many do not. Why not? There are many factors, but one of the most common is the difficulty in getting paid for it (reimbursement). Wayman and his group (2000) demonstrated a cost savings by using maggot therapy for venous stasis ulcers. But when insurance companies do not pay for maggot therapy then the health care practitioners and institutions (or the patients themselves) have to pick up the costs themselves. From their perspective, maggot therapy is not a cost savings.

It is a shame when our health care system pays thousands of dollars for an amputation but not $100 for maggots, which reportedly saved limbs in 50% of the cases where it was tried (Sherman, 2002).

The reason that it can be difficult to get reimbursement for maggot therapy --- sometimes requiring the doctors or patients to appeal an initial rejection letter several times --- is that there is no specific procedure ("CPT") code for the procedure of maggot therapy, nor a product ("HCPCS") code for the maggots. Just about every medical procedure, from drawing blood to transplanting hearts, is designated with a CPT code which can be listed on Medicare, Medicaid and private insurance forms. Just about every medical product, from empty syringes to ventilators, has a designated HCPCS code, which can be listed on the insurance forms so that the patient or health care provider can be reimbursed.

But in 2004, the American Medical Association (AMA) Committee for CPT Coding declined to issue a specific CPT code for maggot therapy, stating that reimbursement should come from a HCPCS code for the maggots. The Center for Medicare and Medicaid Services (CMS) issues HCPCS codes. Then the Center for Medicare and Medicaid Services declined to issue a HCPCS code for the maggots, stating that reimbursement for maggot therapy should come from billing for the procedure with a CPT code.

Today, the same volleying is playing out all over again: AMA says that CMS should provide a billing code, and CMS says that AMA should provide the billing code. Meanwhile, there is no billing code and patients and their care providers are forced to battle their insurance providers to get fair reimbursement for a safe, effective and appropriate (albeit unconventional) therapy.

That is what prompted me to begin writing about the contemporary issues (research, accomplishments, opportunities, and, yes, battles) concerning biotherapy.

I will have to continue this story tomorrow . . . .