Advocacy & Practice Updates — Clinical Updates

WPS Begins Paying Previously Denied Syfovre Claims after ASRS Opposition

Two weeks after ASRS and other retina specialists weighed in on the medical necessity of Pegcetacoplan injections (Syfovre), the Medicare Administrative Contractor, WPS, has now begun paying previously denied claims. Nationally, WPS was an outlier in its unwritten policy to deny Syfovre, claiming that it did not view the drug as medically necessary. ASRS was not able to find examples of a MAC acting independently to deny coverage of an FDA-approved treatment covered by Medicare, and therefore believed this situation set a bad precedent and should be prevented before potentially spreading. Some claims are being adjudicated at invoice, which is allowed for new products until an effective J-code is published in CMS’s ASP Pricing File. 

If your Syfovre claims have not been paid, please contact Monica Horton, ASRS director of practice management.

Posted September 13, 2023