Reimbursement for Aquablation Therapy
PROCEPT BioRobotics is committed to supporting healthcare professionals navigate the insurance process. This section contains reimbursement resources, information, tools and FAQ’s that may be useful.
United States Reimbursement
Overview: Aquablation Therapy is a new BPH surgical therapy receiving FDA clearance in December 2017. Medicare and private insurance companies may consider new treatments investigational and experimental and therefore may not initially cover and pay for these new procedures.
However, the Aquablation Reimbursement Center (ARC) is a case-by-case reimbursement support service for providers who perform Aquablation procedures. ARC Reimbursement is a HIPAA compliant entity that provides the following services:
- Coding & Coverage Information
- Eligibility & Benefit Verification
- Pre-service appeals
- Post-service appeals
Email and Voice Mail messages returned within one business day
Phone: 833 230 2406
Fax: 650 649 1856
Select from the links below to download additional reimbursement resources:
Coverage – Medicare
Medicare has issued final positive coverage policies covering Aquablation therapy for Medicare and Medicare Advantage patients in the United States. Effective November 2020, positive coverage policies were available in the following 12 states: Connecticut, Illinois, Maine, Massachusetts, Minnesota, New Hampshire, New York, Rhode Island, Vermont, Wisconsin, Kentucky and Ohio. Positive coverage policies for the remaining 38 states are effective December 2020.
Coverage – Private Payers
Aquablation therapy is currently covered by the following private payers.
- Health Care Services Corp (HCSC)
- Emblem Health
- Blue Cross Blue Shield – Massachusetts
This list will be updated as favorable coverage is attained.
Prior Authorization – Medicare
Medicare does not require prior authorization. However, ARC support is encouraged as well for Medicare.
Prior Authorization – Private Insurance
Private insurers may require prior authorization for Aquablation Therapy. Prior authorization requirements vary by payer. ARC supports providers with private payer prior authorizations.
Denials and Appeals
Patients and providers have the right to appeal prior authorization denials, claim denials and insufficient payment. Each payer has a defined appeals process. Appeals ensure that patient claims are given appropriate consideration and review. Claim appeals also address payer non-coverage. ARC supports physician offices with the payer claim appeal process.
Reimbursement and coverage vary by geography in markets outside the United States. We recommend patients contact their local physician providers to determine if Aquablation Therapy is available.
To request assistance with reimbursement questions or prior authorization, please contact us directly.
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Disclaimer: This information is provided by PROCEPT BioRobotics for illustrative purposes only and does not constitute legal or reimbursement advice. All codes supplied in this guide are for information purposes only and represent no statement or guarantee by PROCEPT BioRobotics that these codes will be appropriate or that reimbursement will be made in a specific situation.
The information provided in this document was obtained from third-party sources and is subject to change without notice as a result of changes in reimbursement laws, regulations, rules, policies, and payment amounts. All content is, general in nature, and does not cover all situations or all payers’ rules and policies. It is the responsibility of the hospital or physician to determine medical necessity, the proper site for delivery of any services and to submit appropriate codes, modifiers and charges for a particular patient and/or procedure. Any claim should be coded appropriately and supported with adequate documentation in the medical record. PROCEPT BioRobotics encourages providers to submit claims for services consistent with FDA clearance and approved labeling.
Hospitals and physicians should consult with appropriate payers, including Medicare Administrative Contractors, reimbursement specialists and/or legal counsel for specific information on proper coding, billing, and payment levels for healthcare procedures. PROCEPT BioRobotics makes no express or implied warranty or guarantee that (i) the list of codes and narratives available through this resource is complete or error-free, (ii) the use of this information will prevent difference of opinions or disputes with payers, (iii) these codes will be covered or (iv) the provider will receive the reimbursement amounts set forth herein. Reimbursement policies can vary considerably from one region or payer to another and may change over time.