Medicare coverage for BCG

1 day 8 hours ago #61150 by LandJax
Replied by LandJax on topic Medicare coverage for BCG
My BCG therapy was always Part B and although the deduct was aggressive $500.00 per 6 sessions it was covered.

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1 week 6 days ago #61099 by Paraman
Replied by Paraman on topic Medicare coverage for BCG
Thank you for the reply. I feel much better now. I will speak to the doctor's office Monday. I am sure we will find the solution. 
I am little nervous about the would be side effects, but, waiting and hoping

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2 weeks 3 hours ago #61098 by Jack R
Replied by Jack R on topic Medicare coverage for BCG

All 33 of my BCG treatments, the last in 2018, were covered under original medicare, paid for by medicare, with the regular 20% paid by my secondary. 

Obviously, you were given an Advance Beneficiary Notice (ABN) by your treater stating that medicare MAY not cover BCG. If a billing department is not sure, they may issue an ABN to protect themselves, just in case. 

An inexperienced biller with outdated materials may have missed a change in procedure codes effective July 1, 2019. The following article from Medicare (CMS)  may help when you have a conversation with the caregivers billing staff.

"Due to the current shortage of Bacillus Calmette-Guérin (BCG) for intravesical instillation it may be necessary to maintain ongoing treatment for bladder cancer with this product at less than the Food and Drug Administration (FDA) label dose of 81 mg (1 vial) per instillation. In response to this situation, Centers for Medicare and Medicaid Services (CMS) has created a new HCPCS code by which to report BCG which will allow for reporting of doses less than 1 vial per instillation. HCPCS code J9030 BCG live intravesical instillation, 1 mg becomes effective 7/1/2019 and replaces HCPCS code J9031 BCG intravesical per instillation. HCPCS code J9031 BCG intravesical per instillation will no longer be payable by Medicare as of 7/1/2019. HCPCS code J9030 should be reported with the number of units corresponding to the units being equal to the number of milligrams actually instilled per treatment, as the unit equals 1 mg for the new code."

Read the full article. REMEMBER, billing and coding changes happen frequently. Try to work WITH the biller, avoid all disagreement and arguement. Tell the biller that a friend has had original medicare pay all but the medicare copay/deductible/share of cost - see if you can get this cleared up quickly.

Good luck !

6/2015 HG Papillary & CIS
3 Years and 30 BCG/BCG+Inf
Tis CIS comes back.
BC clear as of 5/17 !
RCC found in my one & only kidney 10/17
Begin Chemo; Cisplatin and Gemzar
8/18 begin Chemo# 3
Begin year 4 with cis
2/19 Chemo #4
9/19 NED again :)
1/2020 CIS is back
Tried Keytruda, stopped by side effects
Workin on a new plan for 2021

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2 weeks 7 hours ago #61097 by sara.anne
Replied by sara.anne on topic Medicare coverage for BCG
 I am not an expert on medical coverages since I only have Medicare and other sources cover my prescriptions. However I am under the impression that BCG is not considered a prescription item but should be covered under Medicare as a Medicare treatment. You might want to ask your doctor about  since I bet it is not included under Medicare part D . 

 Please let us know the result since others may have the same issues. 

Sara Anne

Diagnosis 2-08 Small papillary TCC; CIS
BCG; BCG maintenance
Vice-President, American Bladder Cancer Society
Forum Moderator

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2 weeks 9 hours ago #61096 by Paraman
Medicare coverage for BCG was created by Paraman
I was browsing to find some help with insurance coverage problem. came across this site, hope i am not out of step

I have high grade, not muscle involved bladder cancer, due to start BCG next week.
Had my second look surgery on December 15th, due to start treatment in a week. I just found out my PartD plan thru Medicare will not cover BCG. Is that true? 
I never expected this. They say I can appeal, i will, but, do not have the time for it now. Do not want to wait to start the treatment.
Hope some one can help.

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