Hi!
I have been a faithful reader of the Beacon for quite awhile. This is my first posted question, so I hope I make sense!
I had a stem cell transplant in July of 2014. My oncologist gave me a schedule of childhood vaccinations and told me to have my internist give them to me. I gave the schedule to my internist and received all of the vaccinations.
Medicare, however, denied coverage, and here it is 2016 and I'm still fighting to get them covered. $1000 out of my pocket! Now I've been told that Schedule D might cover them.
Does anyone know what the heck I'm supposed to do? Is there someone I should call? Has anyone had their post stem cell transplant vaccinations covered? Help!
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Terri E - Name: Terri E
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Feb., 2012
- Age at diagnosis: 62
Re: Medicare coverage of post transplant vaccinations?
Hi Terri E,
You say you have been wrestling with Medicare over this since 2014. Have you appealed their denial? Can you share a summary of your communications with them over this issue?
I ask because I am pretty sure they will cover re-vaccination required to restore your immune system's functioning, but the diagnostic codes with which the claim is submitted have to reference the transplant. Your oncologist should have worked with your internist to make sure this was done; my guess is that it may not have been. And yes, some of the vaccines may be covered under Part B, and some under Part D.
Also, for many coverage issues, there is no national Medicare policy. Instead, coverage for some procedures / treatments can depend on where you live. Medicare.gov only lists those items that are covered nationally. That's why I am wondering about your contact with Medicare so far over the re-vaccinations.
You say you have been wrestling with Medicare over this since 2014. Have you appealed their denial? Can you share a summary of your communications with them over this issue?
I ask because I am pretty sure they will cover re-vaccination required to restore your immune system's functioning, but the diagnostic codes with which the claim is submitted have to reference the transplant. Your oncologist should have worked with your internist to make sure this was done; my guess is that it may not have been. And yes, some of the vaccines may be covered under Part B, and some under Part D.
Also, for many coverage issues, there is no national Medicare policy. Instead, coverage for some procedures / treatments can depend on where you live. Medicare.gov only lists those items that are covered nationally. That's why I am wondering about your contact with Medicare so far over the re-vaccinations.
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MrPotatohead - Name: MrPotatohead
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: March, 2015
- Age at diagnosis: 65
Re: Medicare coverage of post transplant vaccinations?
Hello Terri,
Mr. PH does as usual raise a good point as to where you are. I assume that it is in the U.S., however, it does appear that the UK system may be referred to by the same name (and maybe other countries, too). Your childhood vaccinations are a direct requirement of the autologous stem cell transplant and therefore should be covered. In our center, the oncologist gives the vaccines and writes it up in a way that it is covered.
I do not have direct experience with Medicare, but it seems to me if the doctor resubmitted and gave the special circumstance, that it should be covered, and as mentioned, there is the appeal process, which I would think would be appropriate at this time. Hopefully, other posters can share with you some direct experience.
Good luck to you.
Mr. PH does as usual raise a good point as to where you are. I assume that it is in the U.S., however, it does appear that the UK system may be referred to by the same name (and maybe other countries, too). Your childhood vaccinations are a direct requirement of the autologous stem cell transplant and therefore should be covered. In our center, the oncologist gives the vaccines and writes it up in a way that it is covered.
I do not have direct experience with Medicare, but it seems to me if the doctor resubmitted and gave the special circumstance, that it should be covered, and as mentioned, there is the appeal process, which I would think would be appropriate at this time. Hopefully, other posters can share with you some direct experience.
Good luck to you.
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JPC - Name: JPC
Re: Medicare coverage of post transplant vaccinations?
I am two years post transplant and on Medicare with a plan F supplement. I have had all of my inoculations and they were all covered by Medicare. All of my inoculations were administered at the transplant center not my GP. I think that is the key to your problem and your GP or family physician needs to code the Medicare billing properly to associate it with your transplant.
Good luck.
Good luck.
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Dano - Who do you know with myeloma?: Me
- When were you/they diagnosed?: Jan 2014
- Age at diagnosis: 65
Re: Medicare coverage of post transplant vaccinations?
Hi Terri.
I also believe this is an issue of billing (and I'm an internist in primary care). If your vaccines are associated with the ICD-10 code Z94.81 (Bone Marrow Transplant Status), they should be covered either through your PCP visits (Part B) or via Part D.
My husband starts his s/p ASCT vaccines with a flu shot on Tuesday and will start his "childhood vaccines" in December as gaps in his maintenance chemo permit.
Good luck.
rick
I also believe this is an issue of billing (and I'm an internist in primary care). If your vaccines are associated with the ICD-10 code Z94.81 (Bone Marrow Transplant Status), they should be covered either through your PCP visits (Part B) or via Part D.
My husband starts his s/p ASCT vaccines with a flu shot on Tuesday and will start his "childhood vaccines" in December as gaps in his maintenance chemo permit.
Good luck.
rick
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rick - Name: rick
- Who do you know with myeloma?: husband
- When were you/they diagnosed?: nov 2015
- Age at diagnosis: 50
Re: Medicare coverage of post transplant vaccinations?
Thank you all for your replies. I live in the U.S., in Indiana.
Yes, the billing department. at my GP office did not send the correct ICD10 code of Z94.81 when they first billed to Medicare. Supposedly, they resent with the right codes and it was still denied.
I am very frustrated by all of this. I don't feel like I'm the one who should be dealing with this. (Whining)
I guess I will have to appeal, as suggested, and try to get it resolved that way.
Again, thank you all. You have given me the determination to continue to pursue this even though it's driving me crazy.
Yes, the billing department. at my GP office did not send the correct ICD10 code of Z94.81 when they first billed to Medicare. Supposedly, they resent with the right codes and it was still denied.
I am very frustrated by all of this. I don't feel like I'm the one who should be dealing with this. (Whining)
I guess I will have to appeal, as suggested, and try to get it resolved that way.
Again, thank you all. You have given me the determination to continue to pursue this even though it's driving me crazy.
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Terri E - Name: Terri E
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Feb., 2012
- Age at diagnosis: 62
Re: Medicare coverage of post transplant vaccinations?
Terri E,
I too could benefit from vaccinations after my stem cell transplant. I'm hung up on the $1000 charge for childhood vaccinations. The cost didn't stem from a titers test, did it? I wonder if I could cherry pick the cheaper vaccinations? I had wanted my PCP to give them to me, however I'll inquire with my oncologist again trying to avoid your billing situation.. Last meeting with oncologist he said he would order them, but the infusion clinic had no order.
I too could benefit from vaccinations after my stem cell transplant. I'm hung up on the $1000 charge for childhood vaccinations. The cost didn't stem from a titers test, did it? I wonder if I could cherry pick the cheaper vaccinations? I had wanted my PCP to give them to me, however I'll inquire with my oncologist again trying to avoid your billing situation.. Last meeting with oncologist he said he would order them, but the infusion clinic had no order.
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blueblood - Name: Craig
- Who do you know with myeloma?: Myself
- When were you/they diagnosed?: March 2014
- Age at diagnosis: 54
Re: Medicare coverage of post transplant vaccinations?
Hi to all,
I am in Canada, but thought I could chime in on this topic. My vaccinations after the stem cell transplant could only be authorized through the bone marrow transplant clinic. The approval hinged on my immune status, whether or not the oncologists there thought I was now healthy enough to receive them. I had tried calling the public health clinic to book my own appointments, but that was not how this process works. Thus I did eventually get all of my vaccinations back, over a two year period. This was not through my family doctor or even my regular oncologist, but thru the stem cell transplant unit. So maybe that would help those who are trying to get vaccinations approved as part of their stem cell transplant process.
I am in Canada, but thought I could chime in on this topic. My vaccinations after the stem cell transplant could only be authorized through the bone marrow transplant clinic. The approval hinged on my immune status, whether or not the oncologists there thought I was now healthy enough to receive them. I had tried calling the public health clinic to book my own appointments, but that was not how this process works. Thus I did eventually get all of my vaccinations back, over a two year period. This was not through my family doctor or even my regular oncologist, but thru the stem cell transplant unit. So maybe that would help those who are trying to get vaccinations approved as part of their stem cell transplant process.
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Nancy Shamanna - Name: Nancy Shamanna
- Who do you know with myeloma?: Self and others too
- When were you/they diagnosed?: July 2009
Re: Medicare coverage of post transplant vaccinations?
Blueblood,
No, the cost did not stem from a titre test. I received the vaccinations over a period of about one and a half years. The billing kind of trickled in, so I didn't have to pay the $1000 all at once. My guess is if they submit the correct codes with the billing, it will be paid. I think I got caught in the twilight zone.
I haven't heard of anyone else being denied. Just me.
I have asked my stem cell transplant oncologist to send me a letter of medical necessity to send in with my appeal. Maybe that will help.
No, the cost did not stem from a titre test. I received the vaccinations over a period of about one and a half years. The billing kind of trickled in, so I didn't have to pay the $1000 all at once. My guess is if they submit the correct codes with the billing, it will be paid. I think I got caught in the twilight zone.
I haven't heard of anyone else being denied. Just me.
I have asked my stem cell transplant oncologist to send me a letter of medical necessity to send in with my appeal. Maybe that will help.
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Terri E - Name: Terri E
- Who do you know with myeloma?: Me
- When were you/they diagnosed?: Feb., 2012
- Age at diagnosis: 62
Re: Medicare coverage of post transplant vaccinations?
Currently, Medicare does not cover immunizations for preventive care with exception of influenza, hepatitis B, and pneumococcal. The immunizations you receive post transplant may be for Tdap, DTaP, meningococcal, etc. to prevent diseases. The only way these vaccines are covered is if they are for treatment, not prevention. For example, a patient comes to doctor and finds patient due for a tetanus booster. Because the patient is not being treated for an injury or exposed to the toxin, it won't be covered. However, it you cut yourself on a nail and came to ER and got a vaccination, it would be covered due to treatment of the injury.
I'm not saying it's fair to those who have had to have transplants and require revaccination, but that is the current coverage under Medicare part B. Some Medicare advantage plans do cover these vaccinations and if you have Medicare part D, they would be covered under Part D.
"Vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule."
This can be found in section 50.4.4.2 - Immunizations of the Medicare Benefit Policy Manual (link).
Hope this is helpful to understand why you may be responsible for the denied vaccine charges.
Linda (hospital biller in WI)
I'm not saying it's fair to those who have had to have transplants and require revaccination, but that is the current coverage under Medicare part B. Some Medicare advantage plans do cover these vaccinations and if you have Medicare part D, they would be covered under Part D.
"Vaccinations or inoculations are excluded as immunizations unless they are directly related to the treatment of an injury or direct exposure to a disease or condition, such as anti-rabies treatment, tetanus antitoxin or booster vaccine, botulin antitoxin, antivenin sera, or immune globulin. In the absence of injury or direct exposure, preventive immunization (vaccination or inoculation) against such diseases as smallpox, polio, diphtheria, etc., is not covered. However, pneumococcal, hepatitis B, and influenza virus vaccines are exceptions to this rule."
This can be found in section 50.4.4.2 - Immunizations of the Medicare Benefit Policy Manual (link).
Hope this is helpful to understand why you may be responsible for the denied vaccine charges.
Linda (hospital biller in WI)
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Linda in WI
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