Reimbursement for Needle Aponeurotomy and for Xiaflex

Needle aponeurotomy (NA) is referred to as percutaneous fasciotomy in the AMA Common Procedural Terminology (CPT) listing. CPT codes are the standard language used by health care providers and the insurance industry regarding reimbursement. Several years ago, Blue Cross of Massachusetts quietly removed the code for NA (26040) from their list of reimbursed procedures, as if it didn't exist. It's baffling - the procedure code has been part of the AMA coding system for the duration of the system, and is an established Medicare reimbursed code.

Given the progressively slippery changes of the unregulated business practices of the private health insurance industry over the last 30 years, this may be part of a larger strategy of benefit denial - quietly removing codes for services which, because they are uncommonly used, won't generate a large public outcry. The code removal may have been triggered by the fact that 26040 was almost never filed as a claim before NA came to the US in 2003. In the same way that policyholders risk being dropped when they file a claim, the code may have been dropped because it began generating a cost. Whatever the reason, this is part of a larger trend, as reflected by a 2009 survey of the members of the American Society for Surgery of the Hand regarding insurance denials (full text: http://www.dupuytrenfoundation.org/DupPDFs/2009_Insurer_Payments_Survey_Summary_100609.pdf)

NA is far less expensive than open surgery: it would seem profitable for the insurance industry to push patients to have it rather than deny coverage for it, but the opposite is happening. Why? A simple, logical explanation is that there are many people who will not consider open surgery for Dupuytren's, but would consider NA. If the insurance analysis is that the number of open surgery claims is stable but the number of NA claims is rising, this would be interpreted as increased utilization rather than cost savings - an incentive to not pay for NA rather than to support it. From the insurance industry perspective, the best possible outcome is for you to pay for your premiums and then for you to also pay for all of your medical expenses. Time will tell if the same strategy of denial will also affect reimbursement for Collagenase/Xiaflex.