Three Additional Medicare Administrative Contractors Seek Positive Local Coverage Determinations for Another 16 Million Americans

According to SI-Bone Inc., ‘a medical device company that pioneered the use of the iFuse Implant System, a minimally invasive surgical (MIS) device indicated for fusion for certain disorders of the sacroiliac (SI) joint, announced that the Centers for Medicare & Medicaid Services (CMS) has issued its 2016 Hospital Outpatient Prospective Payment System (HOPPS) payment recommendation for MIS SI joint fusion that provides an increased outpatient payment when billing CPT 27279 from $9,266 to $10,538. The proposed payment represents an increase of $1,272 or 14% over the current payment amount. The new payment will become effective January 1, 2016.

In addition to the 2016 HOPPS payment, CMS also announced in their 2016 Medicare Physician Fee Schedule (MPFS) an increase in the physician reimbursement for MIS SI joint fusion procedures when billing CPT 27279 from the current national average of $577 to $722, a 25% increase, also effective January 1, 2016.

“With increased reimbursement for both the surgeon and facility, CMS continues to recognize the increasing value of MIS SI joint fusion,” said Michael Mydra, Vice President of Health Outcomes & Reimbursement at SI-BONE. “We believe that the iFuse Implant System fits strategically with the overall goals of the Affordable Care Act (ACA) by providing a safe, effective, and cost beneficial solution for the treatment of low back pain due to degenerative sacroiliitis and SI joint disruption.”

In addition to the 2016 hospital outpatient and physician payment increases for MIS SI joint fusion, Medicare Administrative Contractor (MAC) Wisconsin Physician Services (WPS), covering the six states of Iowa, Indiana, Kansas, Michigan, Missouri and Nebraska, published a positive local coverage determination (LCD) that provides coverage beginning December 17. The decision by WPS to establish coverage for the procedure was based on a robust body of clinical evidence, over 95% of which is based on SI-BONE’s iFuse Implant System, which shows significant reduction in pain and improvement in quality of life in patients with SI joint dysfunction due to degenerative sacroiliitis or SI joint disruption.’

The approval of the three additional Medicare Administrative contractors now paves the way for our veteran to have the SI joint fusion procedure. Our veteran has been on a waiting list for over two years and lives in constant pain. This procedure has been successful for other patients and doctors anticipate much improvement to his quality of life and decreased pain level. He is a candidate selected for the first group of patients warranting surgery and will be monitored afterwards to determine if the procedure is a beneficial solution for other patients.

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