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sculptra insurance coverage
Jan 27, 2009

IN your blog in Nov '08, you gave a man advice on getting coverage from his insurance company for Sculptra treatments. you gave a diagnosis code of 272.6, but I could not find any mention of a PROCEDURE CODE......which my doctor's office says is required in order to file a claim with Medicare or any other insurer. The Sculptra reps were unable to help. Can you please tell me the procedure code to be used? Thank you.

Response from Mr. Vergel

This is information provided to me by Dr Doug Mest, one of the pioneers in Los Angeles in the use of Sculptra. You may want to read about his work at http://www.bpacific.com/media/savingface.pdf and have your doctor contact him. This is an email he sent me to answer your question:

"As for which codes to use, therein lies one of the issues with Insurance billing and subsequent payment for the physician doing facial lipoatrophy treatments. No current CPT code accurately describes what we are doing and/or pays enough per session or allows the frequency of retreatment.

However, here are the available codes: 11952 injection of subcutaneous filler for 5-10 ccs 11954 for more than 10 ccs This is the most common CPT but pays very poorly.

The other code is 21138 that has been used. This pays more but can only be used every 90 days. So not really how we inject Radiesse, or Sculptra or even Silicone in this country.

Hope this help

Doug"

Reimbursement for Sculptra's labor is very limited and still evolving, unfortunately. A lot has to be done in activism to make this change, but I am afraid most people are too busy with their daily lives to think about helping not only themselves but others who are struggling with reimbursement issues and trying to find answers.

Stay tuned and hope that i get lucky to organize the first "Body Changes in HIV: Reimbursement and Advocacy Issues" Conference some time late summer if I get funding to do it and people who care to join me.

Nelson



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