Dr. John Happel | Jun 26, 2018 | 0
Costs and Reimbursement for Venaseal, Varithena, and Clarivein
How Much Does Medicare Pay and What Is the Cost for the Vein Specialist for the New Vein Procedures?
Costs of Venaseal, Varithena, and Clarivein
- The cost of Venaseal glue is $900.00 per kit.
- The cost of the Clarivein “gun” is $600.00 per pack.
- The cost of Varithena foam sclerotherapy is $3,195 per foam cannister.
- Medicare reimbursement for Venaseal (code 36482) is $2,162.00 (national average)
- Medicare reimbursement for Varithena (code 36465) is $1,624 (national average)
- Medicare reimbursement for Clarivein (code 36473) is about $1800 in New York City.
These prices don’t include procedure packs, gowns, gloves, compression wraps, bandages and other similar ancillary treatment items.
Remember, just because there are codes now available starting January 1, 2018 and they are being reimbursed in some areas of the country, that doesn’t guarantee that the doctor will actually be paid.
For example, in Florida (where overutilization abounds and Medicare fraud is the unofficial state sport), Medicare does not reimburse for these nonthermal nontumescent procedures at all at this time.
Always verify your local plan benefits and follow the required standard authorization protocols before considering billing these new codes.
Profits for the Companies
These new non-thermal non-tumescent (NTNT) techniques are very lucrative for the companies that make them.
Here are approximate profits for the companies that manufacture these new technologies.
The doctors will make about the same (after the costs of the equipment that they must pay for themselves) no matter which of these saphenous vein procedures that they choose.
Here’s what the companies make per saphenous vein treatment:
- Medtronic’s (Venaseal) profit – $900.00 per vein procedure
- Vascular Solution’s (Clarivein) – 600.00 per vein procedure
- BTG (Varithena) will profit $3195/ (if 6 patients per can) – $532.50 per vein procedure
Medtronics is the only company that makes both a thermal (Radiofrequency Closure) device and a non-thermal glue (Venaseal) device.
For each radiofrequency catheter and sheath, they charge the doctor $325.
In contrast, for each glue gun and pack, they charge the doctor $900.
Which device do you think they will be promoting more aggressively?
Glue will be 2.75 times more profitable than radiofrequency Closure for Medtronic but the doctor will get almost exactly the same for doing each procedure.
So how much can the doctor save choosing a different saphenous vein procedure?
Essentially, the doctor makes the same no matter which procedure they choose.
Note: Medicare reimbursement varies according to the area where the procedure is performed.
The reimbursements mentioned above are for only one saphenous vein treated.
For more than one saphenous vein treated concomitantly or by including a phlebectomy, the reimbursement is cut in half.
You save the patient unnecessary visits but get paid less by doing the right thing.
Commercial insurance plans vary widely depending on the area of the country in what they will or will not pay.
Most private health insurance plans still do not cover non-tumescent non-thermal procedures at all.
Inevitable Costs That Are Swept Under the Carpet Down the Road
Two cheers for industry (the entrepreneurial companies who invent, perfect, and invest a lot of money to bring these latest varicose vein advances to market).
They are instrumental in making these wonderful advances possible.
Let’s hear it.
Hip hip – uh, wait a minute.
The main quandary with all of these saphenous vein treatments is the remaining varicose veins which are left after only treating the saphenous vein alone.
None of these three techniques adequately closes the varicose veins themselves.
Let’s face it.
The majority of the patients who come to most vein specialist’s office have CEAP class 2 or C2 disease and are just cosmetic.
Most just want the “bumps” (visible unsightly veins on their skin) gone.
It’s been stated in vein conference presentations by doctors who have the most experience with NTNT techniques that 40% of patients who are examined down the road don’t need further treatment.
Those aren’t the C2 patients that the majority of most vein doctors see.
These well-paid experts (not impartial) are paid consultants who are also the primary investigators in these studies.
They teach that the varicose veins usually become smaller or become asymptomatic.
Often that’s true, if the veins don’t thrombose after the saphenous vein treatment.
What happens to these patients years later?
Having specialized in varicose vein patients for over twenty years, I can attest to the fact that those incompletely treated varicose veins will inevitably enlarge and become much more problematic and more difficult to treat years later.
Dissatisfied patients come to me for treatment from nearby vein docs who have treated only their saphenous veins with persistent and enlarged varicose veins.
They refuse to return to the physician who initially treated only their saphenous veins.
The Problem That Is Ignored – How to Address the Varicosities?
People come to the doctor to get rid of their varicose veins.
If only their saphenous veins are treated, the problem won’t be solved.
Remaining visible varicose veins even though they are asymptomatic are perceived by most patients as a failure of treatment.
Dr. John Happel stated,
When performing a saphenous vein closure that does not require tumescent anesthesia, doctors performing these procedures have to ask themselves, why use this device when the patient will need tumescent anesthesia eventually for phlebectomy of the varicosities? The alternative, sclerotherapy treatment of the varicosities, is complicated with staining problems, significant pain from the chemically induced phlebitis with the larger veins, and a high recurrence rate. Some vein specialists claim that it is debatable whether the adjunctive procedures needs done at all in one third of cases or more. However, I have found that if not done, these same varicose veins will inevitably recur. In many cases, the patient will lose confidence with the original doctor and go elsewhere for definitive treatment.
So, what are treating physicians accomplishing by treating only part of the problem (the saphenous vein only) with these nonthermal techniques?
The answer is that the doctors are kicking the can down the road.
Many patients will not return to the doctor who only closed the saphenous vein because they are unhappy with their recurrence or more accurately the persistence of the same varicosities and the subsequent enlargement of their untreated and neglected varicose veins.
It is most expert’s opinions that the entire superficial venous system’s hypertension has to be unloaded from the saphenous vein to the varicose veins themselves or unhappy patients will be the final result.
The only advantage with the nonthermal saphenous vein ablation techniques appears to be less neurologic complications.
Advertising Claims of Results Made by Vascular Solutions, BTG and Medtronic
Claims of success from companies that make these devices are disingenuous. They focus on the immediate results either right after or just a few months after the procedure.
That is misleading to the treating physicians.
The companies and their highly reimbursed consultants/experts (Read: vein illuminati) omit the high probability of future problems that occur when only their saphenous vein procedure is performed.
It’s like the glamorous ads for drinking alcohol that don’t mention the hangover.
Advertising in this way gives false impressions.
This is exemplified with web site testimonials given by patients only right after the procedures.
That’s deceptive and disingenuous.
These kinds of testimonials imply that their initial results will be long lasting without ever addressing the varicose veins with phlebectomy or sclerotherapy (necessary for treating the smaller varicose veins.)
That’s a big little lie.
The following testimonial is taken from the Clarivein web site.
I went in at the start of summer and had the first leg done and was back at work on a busy change over later that same day and also the next and away dancing at a party within 48 hours.
Five weeks later I went in and had the other leg done – no problems at all. It was pain-free and so easy.
“Now, I just love being on the beach and I am back in shorts and my wardrobe is full of dresses”
The problem with this testimonial is – What will she say years later?
Here is what BTG states about their results:
In 2 placebo-controlled studies, most patients treated with Varithena® (polidocanol injectable foam) experienced these results:
- Improved symptoms – The majority of patients reported improvement in symptoms including heaviness, achiness, swelling, throbbing, and itching (HASTI™ Symptoms).
- Improved vein appearance – The majority of patients experienced improved vein appearance in assessments by both patients and doctors.
Medtronic’s Claims of Benefit with Venaseal
FASTER RECOVERY – PATIENT COMFORT
The VenaSeal™ closure system is designed to allow rapid return to normal activities.
The VenaSeal™ closure system is designed to reduce recovery time.
Many patients return to normal activity immediately after the procedure.
Your doctor can help you determine when you can return to normal activity.
Blah, blah, blah.
Other Changes in Coding and Billing Varicose Veins in 2018
One extra related change is to the existing codes of 36470 and 36471. The valuation of these codes will change on 01/01/18 with the RVU’s for 36470 being reduced, and 36471 being increased relative to the amount of time and supplies used for these services. A review of the other commonly utilized phlebology codes shows a fairly static fee schedule for the New Year.
- Additional Information about Varithena
Approximately 90 ccs of foam comes in a can. A maximum of 15 cc’s can be used per procedure. Therefore, at least six patients (or more) can be treated per can of proprietary foam. That comes to $532.50 per patient if 15 cc is used per patient.
The can expires in one month after the first injection has been performed and the gas has been mixed with the polidocanol.
Varithena (BTG) has spent the most money and time developing its proprietary foam compared to the other two non-thermal non-tumescent procedures.
At the present time, its most renown consultants and primary investigators including Kathleen Gibson MD and Nick Morrison MD have switched from endorsing Varithena to endorsing and giving talks for Venaseal.
It has been suggested that Varithena may have its greatest value in treating tortuous recurrent varicose veins as a result of neovascularization.
- Additional Information about Venaseal
It’s interesting that before an insurance code was approved in January 2018, Medtronics (who makes Venaseal glue) charged the doctor $1500 per kit which includes 5 cc of glue. That is enough to treat 100 cm of saphenous veins or the equivalent of two great saphenous veins and one small saphenous vein per sitting. Since insurance was not involved at this time before the insurance codes were available, many doctors would charge $3500 out of pocket per saphenous vein treated. It was suggested that the patient return for a follow up visit in three months to determine if further treatments on the varicose veins themselves were needed. Not treating the residual visible varicose veins results in a lot of unhappy patients.
A big problem with Venaseal is the inflammatory reaction seen after many procedures. The changes observed in the treated veins are consistent with chronic foreign body–type inflammatory response. Granulomas have resulted. The Venaseal glue is an implantable device. It cannot be removed without great difficulty and cosmetic disfigurement (read – scars).
The changes observed in the treated veins are consistent with chronic foreign body–type inflammatory response.
- Additional Information about Clarivein
Clarivein is also known as the MOCA procedure (Mechanical Occlusion with Chemical Assistance) in the United States.
Medicare paid for this procedure under the miscellaneous code 37799 (or 36299 for Noridian) in many areas of the country prior to the present code being approved.
Clarivein billing has been very problematic for some vein doctors before the code 36473 was approved starting Jan. 1, 2017. Many doctors billed the procedure under the “embolization code” – 37241. This code was not appropriate and was considered fraudulent. The AMA verified this. Many physicians performing this procedure were audited and had to pay a lot of money back to the government in addition to not receiving anything for the services rendered. In some cases this recoupment was for hundreds of thousands of dollars.
There are claims that patients experience less pain, discomfort and bruising during and after the Clarivein procedure.
Many commercial payors still consider Clarivein or MOCA to be experimental and investigational at this time.
The Bottom Line
One of the greatest advantages of the nonthermal saphenous ablation techniques is the lack of sensory nerve damage from the procedure.
Costs are obviously important to the patient, the vein specialist, and the company making the treatment to treat varicose veins.
As technology advances, new technologies will continue to be produced by industry to increase their profits.
Lately, it’s been a veritable Vein-fest.
Don’t be the first or the last one to jump on their bandwagon or join their Conga line.
Innovative technology is one of the things that makes our country great.
However, the Blackberry phone, the Edsel, Google Plus, and the DeLorean are examples of some that fell by the wayside.
Choosing the wrong technology for your vein practice can be an expensive mistake in terms of both reputation and costs.
Dakota tribal wisdom says that if you find that you are riding a dead horse, the best strategy is to dismount.