Coverage Policy
Gliadel® Wafer (polifeprosan 20 with carmustine implant) is administered in an in-patient setting. The information displayed below pertains specifically to Medicare. For information tailored to Medicaid or commercial payors, please select the appropriate tab to the right. Coding, coverage, and reimbursement may vary significantly by payor, plan, and patient. See below
Medicare Part A
Medicare does not cover Gliadel® Wafer or most other drugs separately in the hospital inpatient setting. Medicare recognizes MS-DRG 023 for coverage when medically reasonable and necessary according to accepted standards of medical practice. The Centers for Medicare and Medicaid Services (CMS) has not issued a National Coverage Determination (NCD) describing the medically reasonable and necessary use of Gliadel® Wafer. Local Medicare contractors (Fiscal Intermediaries, Carriers or Part A/B Medicare Administrative Contractors (MACs)) may make jurisdiction-specific coverage decisions that relate to Gliadel® Wafer; however, contractors have not published local coverage determinations (LCDs) or other coverage instructions through articles and bulletins as of publication of this guide.
Medicare Part B
Physician services are generally covered under Medicare Part B if they are medically reasonable and necessary for the diagnosis or treatment of an illness or injury according to accepted standards of medical practice. CMS has not issued an NCD describing physician services as they may relate to the implantation of Gliadel® Wafers. Local Medicare contractors may make jurisdiction-specific coverage decisions that relate to Gliadel® Wafer; however, contractors have not published LCDs or other coverage instructions through articles and bulletins as of publication of this guide.
For more information on Medicare reimbursement for Gliadel® Wafer, contact the Eisai Assistance Program at 1-866-61-EISAI or 1-866-61-34724.
Payor Reimbursement
MS-DRG 023
Medicare payment for MS-DRG 023 varies by hospital due to differences in area wages, indirect medical education, disproportionate share status, cost of living adjustments, outliers and other factors. DRG payments to hospitals are made under a prospective payment system and are intended to cover all facility costs associated with an inpatient hospital stay including costs for hospital outpatient services performed within 72 hours of admission. Payment to hospitals excludes payments for physician services.
Gliadel® Wafer Physician Services
Medicare reimbursement for physician services associated with Gliadel® Wafer implantation is based on the national fee schedule that is adjusted for geographic variations and updated annually. Medicare reimbursement is based on the lesser of the adjusted fee schedule amount or actual charges, as follows: physicians are reimbursed for 80% of the allowable amount and the patient or patient’s secondary insurer is responsible for the remaining 20% coinsurance.
