Providers around the country regularly ask us if insurance covers stem cell therapy. If it could, then it would open up the procedures to so many more patients in need. Currently, though, insurance only covers stem cell therapy in two situations:
- For certain malignancies and blood disorders.
- As part of a surgical procedure (allograft add on code).
While stem cell therapy is only covered by insurance in limited situations, R3 does offer a program where regenerative procedures can obtain coverage, added Dr. David Greene Arizona. How does it work?
For certain allograft tissues, Medicare will approve what’s termed a Q code. These Q code products are available for coverage under medical necessity determinations.
The product in the R3 Regenerative Procedure Insurance Program (RPIP) that has a Q code is an amniotic allograft, said Dr. David Greene. This means it is derived from amniotic fluid, which actually comes from a donating mother after a scheduled c-section. There is no harm to either the baby or mother and typically the amniotic fluid is considered medical waste.
The function of amniotic fluid for the fetus involves protection, cushioning, and lubrication. Amniotic fluid is yellow in color and contains a significant amount of nutrients, hormones, and antibodies that are critical for assisting in fetal development.
Here is a list of the functions that amniotic fluid serves:
- Fetus protection
- Temperature control
- Infection Control
- Lung and Digestive Development
- Muscle and Bone Development
- Lubrication
According to the FDA’s definition of homologous use, the function of the donor tissue should serve the same function in the recipient as in the donor. So the functions of protection, cushioning and lubrication easily fit within those parameters.
There are no live cells, including stem cells, in the amniotic allograft. So it would be inappropriate to refer to the amniotic allograft procedure as a stem cell procedure. Considering the list of functions above though that amniotic fluid serves, there is a regenerative component involved.
The specifics of the Q code reimbursement program with R3 Medical are proprietary and are available in a one on one conversation. R3 is one of the few entities nationwide to offer an associated Rebate program, which falls under Safe Harbor and has been approved by various attorney groups. That conversation will include actual reimbursement numbers and EOB’s as well.
The Q code has been in existence for years, and reimbursement is being seen with Medicare, Tricare, Work Comp, and many commercial insurance carriers such as BCBS. The reimbursement is in the network and the R3 RPIP includes all the insurance verifications along with significant marketing as well.
R3 Stem Cell works with a consulting billing company to assist in the reimbursement process. This includes appropriate coding, insurance verifications, medical necessity note templates, etc.
R3 has many practices nationwide benefitting from the Regenerative Procedure Insurance Program, added David Greene Orthopedic. There are quite a few research studies that have shown just how beneficial amniotic allograft procedures have been for joint and soft tissue pain.
One randomized, controlled, single-blinded study published in the Journal of Knee Surgery looked at amniotic allograft versus hyaluronic acid and also a saline control. Over a six month period, the amniotic allograft outperformed the rest in both pain relief and functional improvements.
So the length of pain relief is substantial and the procedures are extremely safe. R3 has not seen a deep infection to date or any type of allergic reaction or rejection. With a significant benefit for patients and absolutely minimal risk, patients have been very excited about the program.
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