Wisconsin Physicians Service Reverses Decision on Kidney Treatment Coverage

Taken from Milwaukee Journal Sentinel article by Guy Boulton

http://www.jsonline.com/business/wisconsin-physicians-service-reverses-decision-on-kidney-treatment-coverage-rt94868-197239931.html

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.

 

http://www.jsonline.com/business/wisconsin-physicians-service-reverses-decision-on-kidney-treatment-coverage-rt94868-197239931.html

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