I agree with Blue Cross. This procedure has no role in AVF creation

Karn
For Wavelinq fistula creation, the code for an ASC is G2171. Im not sure where ur 36837 came from.

The G code has been deleted as far as I know. Not sure why they’re saying it’s an investigational. That’s clearly wrong. The device got FDA approval. You will probably need to escalate that with higher ups at Blue cross. I would contact someone at BD to help with the matter

Jalal: Yes. The G code has been updated to a proper CPT code 36837. BD has not been able to help with this yet. We are trying to reach the BCBS higher ups but they keep it pretty closed loop.

Wissam: CPT codes are not different whether you bill as an ASC, HOPD or OBL.

Karn, thank you for bringing this to the membership's attention. The endovascular committee can help address this concern and provide any necessary additional comments or resources.

Karn: I have had similar denials with certain entities of BCBS. Have had reimbursement in appeal for 5 months for same reasons you mentioned despite providing all the necessary documentation including FDA approval, medical indications, success rates. We have also not been able to obtain prior authorizations from BCBS because they say PA not required but payment will be denied if considered experimental. My center has actually chosen not to perform pAVF in a few patients because BCBS uses vague terms saying it "will be covered if considered medically necessary" but when we discuss with reps about prior authorization they won't commit to saying it will be reimbursed despite all our documentation.

This has been a problem for us since the CPT code went live for both devices in 2023. Sometimes they allowed it sometimes they didn’t.

No good clear permanent global fix yet. You’ll have to try and fight it at the local levels I believe.

Amazing, how these insurers get away with this stuff. Does anybody know if the same is happening with Ellipsys ?

As a member of the Dialysis Vascular Access Coalition (DVAC), ASDIN has learned that several major payers and a number of minor insurance companies have adopted non coverage policies for percutaneous fistula creation (CPT codes 36836 for Ellipsys and 36837 for WavelinQ). In response to the recent ASDIN blog posts, here are copies of the Humana national non coverage policy (https://cdn.ymaws.com/www.asdin.org/resource/resmgr/endoavf/Humana_pavf_noncoverage_0820.pdf) and the Blue Cross Blue Shield of Texas non coverage policy (https://cdn.ymaws.com/www.asdin.org/resource/resmgr/endoavf/Blue_Cross_Texas_non_coverag.pdf) along with a grid showing non coverage of pAVF creation or in cases where we have been successful in reversing decisions it is noted. All Blue Cross regions except Michigan, Massachusetts and their Highmark product in Pennsylvania, Delaware and West Virginia which will cover Ellipsys but not WavelinQ.

Here is a non coverage list - https://cdn.ymaws.com/www.asdin.org/resource/resmgr/endoavf/endoAVF_091924.pdf - as of August. Please let us know if you have other payers who are not covering this procedure so we can add them to our list.

Medicare has coverage for pAVF creation through the new CPT Category 1 codes as noted above and we are not seeing Medicare coverage or payment issues. Most Medicaid plans will cover pAVF but the amounts are usually less than $2,000. Medicare Advantage plans are allowed to create their own Medical Policies if there is no Medicare Local or National Coverage Decision (which there are none for pAVF creation).

Terry F. Litchfield, MPA, CPC
ASDIN Advocacy Chair

Terry: Thank you for the update. I (like many others here) was unaware of these non-coverage decisions from the above mentioned payers. You can add BCBS of NC to the non-coverage list. We need to collectively (as a Society) advocate for unanimous coverage for these codes, else we risk losing this valuable procedure.

Nanda Salem: I'm curious about your comment: "This procedure has no role in AVF creation." Could you please elaborate on this?

Nanda Salem: I'm curious about your comment: "This procedure has no role in AVF creation." Could you please elaborate on this?

Here in Missouri a use both devices and we have had no issues. Mostly is a matter of pre -Authorization.

More on wha Dr Dr Saad remarked , I'm also wondering about Nanda Salem's remark, what do you base your opinion on ?

Interesting discussion.
I and a few others agree with Dr. Salem’s comment. Endo AVF in my opinion at this stage has at best a minimal role in dialysis vascular access creation. The Arizona group of Interventional nephrologist (Rick Mishler et al. ) looked into the technique and decided not to implement and just continue with open creation as the cost and outcomes did not offer any advantage.
I have closely followed the development of this technique in the last decade. When it was commercially launched, I did not feel that it offered any benefit in its current form but started creating them as I did not want to have an opinion without trying a technique.
After close to a thousand open creations with a current Radiocephalic creation rate of 45%, our success rate is close to 89-90%. When I started the Endo AVF, I just wanted similar success at least.
Our Endo AVF success rate is close to 80% but with considerable issues with cannulation at dialysis units and constant visits by our ultrasound technician. I guess the success rate is comparable ( slightly inferior) to our open creations but nothing to brag about.
After my experience I feel that the technique has minimal role due to following reasons:
1. If promoted as the main technique for AVF creation at a center, most patients (45% in our case) will be denied the opportunity of radiocephalic creation.
2. The results are reasonable but do not justify the 4 times cost of the procedure. The numbers discussed at conferences justifying added initial cost because of long term cost benefits are just not true. The technique is more expensive and costs the healthcare system more, period!
3. Cannulation of these AVF is occasionally difficult mainly due to dual flow in both cephalic and basilic system.
4. Maintenance procedures or declots in these AVF are challenging especially for those IN/IR not familiar with the technique or those who feel uncomfortable in arterial access ( which is easier and required in many maintenance procedures on Endo AVF)

We still use the technique on patients, where there is benefit or when patients requests it, as we explain all possible ways to create AVF at the time of vein mappings.

Let’s hope that this technique improves in future but at this time, I feel that it has minimal role in Dialysis Vascular creation and should not be promoted as the first option.

Great discussion. One of the main advantages we've found with endo avf creation is that we can do it immediately, without a 6 month delay from the surgeon/anesthesiologist for "cardiac clearance".

I also believe demographically there is a difference in it's advantages. In southeast Michigan many patients are not candidates for radiocephalic fistula by time they come for initial vein mapping and endo avf is a good option to increase vascular access options over their lifetime. Also, I have run into young patients who refuse surgical creation due to cosmetic concerns and this has been a good option for them in order to maintain dialysis without tunneled catheter. I agree, there is still a need for improvement in technique and all options should be considered based on the individual patient.

I think that depending on your location and availability of surgeons, they need for Percutaneous fist varies. Based on my experience, creating percutaneous AV fistulas I do feel that a distal fistula should be first choice. On the other hand, there is no reason to have patients wait for months for AVF construction.

We must always remember that this techniques are born in North America because of a lack of surgeons interested in fistulas. When it is necessary to wait 6 months for a fistula, everybody hope it is going to be a good one!
The potential problem is to create an elbow fistula with a lot of side branches, instead of a wrist fistula.
In a lot of surgical fistulas, side branches are not a problem in my practice, because I avoid to create them.
Interventionnal nephrologist would be real one when they would create their own fistulas, to bypass the lack of competent and available surgeons. The Phoenix situation is probably a good way?

Thank you so much Dr Pourchez for this excellent response.
The solution to the problem was the training of interventional nephrologists in creating their own AVF’s rather than relying on these sub optimal solutions ( like Endo AVF).
In my center at Toledo, Ohio, the average time from referral to surgery is less than 3-4 weeks, let alone 6 months. As a nephrologist I do my own cardiac/health evaluations and as all of our cases ( including AVG and BBT AVF) are done in local with sedation, no delay occur for so called “cardiac clearance”. The same is true for the center in Arizona and a few others who are doing open AVF creations.
We have been doing this for almost a decade now and there is plenty of data supporting this approach. Unfortunately ASDIN leadership has never supported such initiatives. A few times me and Rick Mishler have tried to convince the leadership to formally promote this approach but to no avail. I have never understood this lack of enthusiasm on part of ASDIN.
Hopefully things will change one day.
Thanks again.

Correction - We regret the error in our previous post and want to take this opportunity to clarify!

We want to offer a correction to our 9/19 post - Please note that the information related to Blue Cross Blue Shield and Highmark was incorrect.
• BCBS of MI covers both devices
• BCBS of MA withdrew their non-coverage of both devices and now has silent coverage of both devices
• BCBS Highmark has removed non-coverage for their Medicare Advantage plan and now has silent coverage of both devices
Please Note: We are still hearing in all areas where there have been noncoverage decisions, that some centers are able to obtain authorization and payment. DVAC and ASDIN continue to advocate for full coverage of both technologies for the ESKD patient.