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Medicare Fistula Coverage
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Medicare Fistula Coverage

Society members have expressed a growing concern over the lack of access to supplies for patients who have nonsurgical and surgical related fistula.  These groups of patients are falling into a coverage gap that exists in post-acute, post home care with access to supplies. This issue has been noted in patients both pediatric and adult and more information can be found in a White Paper prepared by the Society.  In short, the task force sees two distinct problems:

  1. Despite available products, Medicare/Medicaid coverage is limited to only fistulas that are caused or treated by a surgical procedure.  Products for spontaneous fistula are not covered. 
  2. There is only one covered product (Wound Pouch A6154) which is insufficient because fistulas very greatly in size location, output and complexity.

In an effort to close this coverage gap the Society has been working with other stakeholders to engage CMS in a conversation about how to change coverage policy so patients have access to these important supplies.  We are hopeful that this advocacy will result in a change in CMS coverage policy to ensure access.  

Inquiry was cast to the DME MAC physicians with response that CMS coverage issues are not in the domain of the group.  The Public Policy and Advocacy Coordination team is currently working on next steps for this project including direct outreach to CMS staff. 

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