Medicare Panel Recommends Increasing Payments for Inspire Therapy to Ambulatory Surgical Centers

A Centers for Medicare and Medicaid Services (CMS) panel has unanimously approved a recommendation to increase the previously proposed reimbursement for Inspire procedure performed in ambulatory surgical centers.

Following US Food and Drug Administration approval in 2014, reimbursement for Inspire therapy was determined by the American Medical Association’s (AMA) Current Procedural Technology (CPT) code panel, which concluded in 2016 that the procedure should be conducted under CPT code 64568, the same code utilized for the procedure to implant a vagus nerve stimulator (VNS) to treat epilepsy, with an add-on code (CPT 0466T) for the sensing lead.

Last year, the AMA panel created a new category I CPT code for the Inspire procedure (CPT 645X1), which will go into effect on January 1, 2022. In July 2021, CMS issued proposed rules for the new CPT code which, if implemented, would have significantly reduce the reimbursement for Inspire procedures in an ambulatory surgical center to approximately $17,500, representing a $7,000 reduction from the current code 64568. On the contrary, the hospital reimbursement for the new code proposed a 3% increase to just over $30,000.

In determining the reimbursement rates under the proposed rules, CMS defaulted to a device offset rate of 31%, rather than retain the existing offset rate of 85.71% that was previously applied prior to the CPT code split from vagus nerve stimulator. The device offset is generally the device-related portion of the relevant procedure code under the Healthcare Common Procedure Coding System (HCPCS). The result of this proposed change by CMS reduced the payment for the Inspire procedure from nearly $25,000 to approximately $17,500.

On August 23, 2021, CMS convened the advisory panel on hospital outpatient payment to review several considerations, including ambulatory payment classifications for multiple device types. Inspire presented historical patient data for Inspire therapy at the advisory panel meeting.

The panel voted unanimously, with no abstentions, to recommend to CMS that it reset the device offset rate to 85.71%. The panel also unanimously recommended there be no multiple procedure discounting, or at least that any applied discounting policy be consistent with that applied to other devices.

CMS will review the panel’s recommendations, and the final rules will be published later in 2021. The reimbursement rates are expected to go into effect on January 1, 2022.