The Medicare Administrative Contractor Novitas Solutions removed minimally invasive sacroiliac joint fusion from non-coverage, according to an SI-BONE news release.
The company will now cover MIS SI joint fusions on a case-by-case basis, including the use of the iFuse Implant System. Here are five things to know about this decision and the rapidly changing acceptance of MIS SI joint fusion:
1. Novitas has removed CPT code 0334T, which was previously used to report the iFuse procedures, from the “Services That Are Not Reasonable and Necessary.” This is following Palmetto’s decision on Feb. 20 to remove the code from its non-covered services. There are more than 11 million Medicare beneficiaries covered by Novitas that will now have access to MIS SI Joint fusion.
2. The decision will allow Medicare beneficiaries in 11 states and the District of Columbia to access MIS SI Joint fusion. Now 15 states and 15 million beneficiaries have access to the procedure. “We are delighted to learn that Novitas has joined Palmetto in making MIS SI joint fusion available to Medicare beneficiaries for whom the procedure is medically necessary. This decision by Novitas provides further validation that MIS SI joint fusion is supported by strong clinical evidence and confirms that the procedure is consistent with generally accepted standards of medical practice in the medical community and is safe and effective,” said Vice President of Health Outcomes and Reimbursement for SI-BONE Michael Mydra.
3. Medicare beneficiaries aren’t the only ones with increased access to MIS SI joint fusion; the American Medical Association announced the procedure would transition to a Category I CPT code effective Jan. 1, 2015. "We've gone from a Category I to Category III and back to Category I code with this procedure in about a year period. I think that speaks to the fact that the medical terrain is changing at a phenomenal rate, and physicians and industry are responding quickly to answer questions about the effectiveness of their procedures,” said Morgan Lorio, MD, Chair Coding & Reimbursement Task Force for the International Society for the Advancement of Spine Surgery, in a Becker’s Spine Review report.
4. In the wake of recent coverage announcements, SI-BONE completed a $33 million growth capital financing round at the end of April. The funds will be used for expanding research and development, medical affairs, regulatory compliance and reimbursement. The company would also like to expand operations internationally. “We expect significant additional clinical publications over the next 12 months with long term data,” said Mr. Mydra in the news release.
5. In a retrospective report of 263 patients at seven different sites, researchers compared open and minimally invasive SI joint fusions. The patients who underwent MIS SI joint fusion with iFuse had greater pain relief and better perioperative measures. The operative time was also reduced from 163 minutes in the open group to 70 minutes in the MIS group. The MIS group also had a shorter length of stay at the hospital--1.3 days compared to 5.1 days for the open group. Finally, complication rate was lower for the MIS group, at 3.5 percent compared to 44 percent in the open group.
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