image: Vial of germ free Medical Maggots. Since 2004, they have been available in the US only by prescription. view more
Credit: Photo courtesy of Monarch Labs, LLC, Irvine, CA
At its upcoming Public Meeting on April 22, 2008, the Centers for Medicare and Medicaid Services (CMS) will solicit public input for the establishment of a Healthcare Common Procedure Coding System (HCPCS) for medicinal maggots.
Level II of the HCPCS is a standardized coding system that is used to identify products, supplies, and services not included in the Current Procedural Terminology (CPT) coding system assigned by the American Medical Association to describe most procedures. Together, CPT codes and HCPCS codes are the mechanism by which most procedures and medical products in this country are listed on insurance claim forms and subsequently reimbursed.
Medical grade maggots have been used in this country for almost 80 years, but it was not until 2003 that they began to be regulated by the Food and Drug Administration (FDA). In January, 2004, Medical Maggots became the first living organism to receive marketing clearance by the FDA as a prescription medical device. Based on efficacy and safety studies, Medical Maggots can be marketed for the treatment of non-healing necrotic wounds, such as pressure ulcers, most diabetic foot ulcers, chronic leg ulcers and traumatic wounds.
A treatment supply of medicinal maggots costs less than $100, but reportedly can save thousands or even tens of thousands of dollars in medical, surgical and hospital costs. Yet, CMS still has not provided the health care industry with a reimbursement code for this critical wound care product.
The AMA considered a CPT code for maggot therapy 3 years ago and again last month. Their decision remains unchanged: clinicians should be reimbursed for their time doing maggot therapy by using standard wound care procedure reimbursement (CPT) codes that already exist. Reimbursement for the additional cost of the maggots, they said, should be obtained by using a designated HCPCS code, to be assigned by CMS.
The purpose of the upcoming Public Meeting is to obtain industry and public reaction to CMS’ preliminary coding recommendations. According to the published meeting agenda, CMS officials plan to recommend that medicinal maggots not be given a reimbursement code because "No insurer (i.e., Medicare, Medicaid, Private Insurance Sector) identified a national program operating need to establish a HCPCS Level II code to identify Medical Maggots (http://www.cms.hhs.gov/MedHCPCSGenInfo/Downloads/SO-April22_2008.pdf).
Members of the BioTherapeutics, Education and Research (BTER) Foundation disagree with the CMS recommendation, and plan to demonstrate that beneficiaries, health care professionals and taxpayers do see a need for patients and their doctors to be able to use, code, and be reimbursed for using medicinal maggots. According to the charity’s director, Dr. Ronald Sherman, BTER Foundation representatives will remind CMS officials that the same efficacy and safety studies that FDA evaluated before clearing Medical Maggots for marketing in the U.S. also demonstrated lower medical costs and high rates of limb salvage. In fact, when used on patients who failed all other medical and surgical treatments for their gangrenous wounds were offered only amputation or maggot therapy, 40-50% of patients who chose maggot therapy healed their wounds and saved their limbs. BTER Foundation members also will present study data that shows that many doctors will not prescribe maggot therapy when their insurance companies do not, or are perceived not to reimburse for the maggots. “Not having a reimbursement code for medicinal maggots is like not allowing maggots on the formulary of any insurance company,” he says. “This is not what we would expect from Medicare, as the leading proponent of high-quality, equitable, cost-efficient medical care.“
BTER Foundation Board member Pam Mitchell will also defend maggots at the hearing. She recently published her own experience in which she attributes medicinal maggots as saving her legs and her life (Maggots, Miracles Me, published 2007 by Xulon Press). “Until a HCPCS code is established for medicinal maggots, she says, “maggot therapy may remain more available for the wealthy who can pay one or two hundred dollars out of pocket rather than the majority of Americans, whether they have medical insurance or not. It seems like it is often easier to get your legs chopped off, and insurance will even pay for it, but not maggot therapy, even though maggot therapy could save your legs and a lot of money, too.”
The BTER Foundation, established in 2003, is a not-for-profit organization dedicated to supporting patients, educating health care providers and furthering research in biotherapy such as maggot therapy, leech therapy, cancer-detecting and service dogs, and the use of other living animals to diagnose or treat illness.
More information about HCPCS coding can be found at: http://www.cms.hhs.gov/MedHCPCSGenInfo/
More information about the public hearing can be found at: http://www.cms.hhs.gov/medhcpcsgeninfo/08_hcpcspublicmeetings.asp
More information about the BTER Foundation can be found at their website: http://www.BTERFoundation.org