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Vivaglobin® Reimbursement when Administered through an Infusion Pump qualify under Durable Medical Equipment (DME) provisions

Vivaglobin® Reimbursement when Administered through an Infusion Pump qualify under Durable Medical Equipment (DME) provisions

In June 2006, the Medicare Durable Medical Equipment Regional Carriers (DMERCs) determined an infusion pump to be an integral part of Vivaglobin® therapy, therefore, Vivaglobin® is covered under the DME provisions of Medicare Part B for primary immune deficiency diagnoses1. We have received many questions regarding the reimbursement of Vivaglobin when using the infusion pump.

Under the Medicare statute, section 1842(o)(1)(D) of the Social Security Act, infusion drugs and biologicals furnished through an item of DME are not reimbursed by Medicare through the Average Sales Price (ASP) reimbursement model. Instead, they are paid at 95% of the average wholesale price (AWP) for the product in effect on October 1, 2003. CMS has said that for new DME infusion drugs, the payment rate would be set at 95% of the first available AWP. Only health care providers with DME supplier numbers are to bill the DME MAC or DMERC. Coverage through DME MAC/DMERC includes Vivaglobin® reimbursement as well as reimbursement for the pump, tubing and ancillaries.

1 As of July of 2006, CMS selected new contractors to process claims related to DME, replacing the four DMERCs with four DME Medicare Administrative Contractors (DME MACs), although the replacement of one of the DMERCs has been delayed because of a contract bid protest. The coverage of Vivaglobin® remained the same after the switch to the DME MACs.

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Reimbursement Alert Online December 2006

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