GAE Reimbursement Challenges
The challenges with genicular artery embolization (GAE) reimbursement vary across carriers. Some payers consider this procedure to be experimental and, therefore, partially or fully deny reimbursement for the associated CPT codes. Carriers that choose not to cover these codes often cite insufficient evidence of clinical efficacy as the primary reason for their decision.
While there are four different (non-head/neck) embolization codes, 37241-37244, GAE is accurately coded with 37242 for osteoarthritis or knee pain.
| 37241 | VASC EMBOLIZE/OCCLUDE VENOUS |
| 37242 | VASC EMBOLIZE/OCCLUDE ARTERY |
| 37243 | EMBOLIZE/OCCLUDE TUMOR/ORGAN |
| 37244 | VASC EMBOLIZE/OCCLUDE ART/VEN BLEED |
- When GAE is performed for osteoarthritis or knee pain, the correct code is 37242.
- But this does not guarantee payment from all payers as some do not recognize this as a payable service for osteoarthritis or knee pain.
- Medicare reimburses for 37242 as no policy exists for this code.
- Some carriers reimburse the selective catheter codes, 36245-36248, while some do not.
- Medicare does have policies for selective catheter placement which do not cover reimbursement for osteoarthritis or knee/leg pain diagnoses.
- Most vascular procedure policies will have vascular diagnosis coverage. Denials for catheterization codes for a non-cardiovascular diagnosis such as osteoarthritis M17.0-M17.9 or knee pain M25.61-M25.562 and M25.569 are muscular-skeletal (MSK), diagnoses which are mismatches, so to speak, of CPT and ICD diagnosis code(s).
- When GAE is performed for hemarthrosis, M25.061 (e.g., post amputation bleed), CPT 37244 (venous or arterial hemorrhage or lymphatic extravasation) is the appropriate code, and most carriers will reimburse for both embolization and selective catheter placements.
- Diagnostic angios are not routinely billed with GAE for osteoarthritis as the diagnosis is established before the procedure is performed rather than during the procedure. Angiography is typically considered “roadmapping” when performed during GAE, and roadmapping is non-billable.
- If a diagnostic angio is billed when performed for osteoarthritis, expect a denial. If reimbursement is received, it does not mean it cannot be recouped via “take back” upon a payment audit by the carrier.
Certain Carrier Policies
Anthem
- Considers GAE to be experimental, investigational, and not medically necessary.
- “Genicular nerve blocks are considered investigational and not medically necessary as treatment for knee pain.”
- “Genicular nerve radiofrequency ablation is considered investigational and not medically necessary as a treatment for knee pain.”
- “Genicular artery embolization is considered investigational and not medically necessary as treatment for knee pain.”
Aetna
- Includes osteoarthritis knee diagnoses M17.0-M17.9 and hemarthrosis, knee M25.061-M25.069 as covered diagnoses, but no specific language regarding genicular artery embolization is addressed.
- Shoulder embolization is facing the same challenges; therefore, caution is advised before taking on this service without the same considerations as the knee.
- Example: Ask why no prior authorization is required. Is it because Aetna considers it to be experimental or a non-covered service and/or medical necessity based on diagnosis?
United Healthcare
- Does not have a specific policy for GAE, but that does not mean that they will reimburse.
- The prior-authorization request should be meticulously vetted for these patients to ensure coverage before the procedure, not during a denial appeal.
Recommendations:
- Each practice must decide whether to balance-bill for non-covered services, write off the charge, or refrain from performing the service.
- Billing for non-covered services: Patients must sign a waiver before being billed.
- Medicare Patients: Use the Advanced Beneficiary Notification (ABN) form to ensure all requirements are met to bill for non-covered services.
- Other Insurance Carriers: Each carrier has its own waiver and specific requirements for obtaining a valid patient signature.
Best Practices:
By proactively reviewing policies and obtaining necessary waivers, practices can ensure compliance, reduce claim denials, and increase payments.
- Review carrier policies: Verify if the procedure and diagnosis are covered under the patient’s plan.
- Clarify prior authorization requirements: If a carrier states that “no prior authorization is necessary,” ask why.
- Is the service not a covered benefit for the patient?
- Is it excluded by the carrier?
- Is it a medical necessity diagnosis issue?
References:
CMS, Aetna, Anthem, United Healthcare
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