Mackenzie McArthur, MPAM, PA-C, DMSc1, Emily A. Simonds, 2, Neilsha Mahase, LPN1, Jennifer Wellington, DO1, Kimberly Gaither, PA-C3, Michael Kennelly, MD4, Baharak Moshiree, MD, MSCI, FACG3, Lisandra Thomazetto Finzetto, BA3 1Atrium Health Wake Forest, Charlotte, NC; 2Campbell University College of Pharmacy & Health Sciences, Buies Creek, NC; 3Atrium Health, Charlotte, NC; 4Atrium Health-Carolinas Medical Center, Charlotte, NC
Introduction: Peristeen is a manual transanal bowel irrigation system designed for patients (pts) with neurogenic bowel dysfunction (NBD) suffering from chronic constipation and fecal incontinence. This control pump with water irrigation has been shown to improve symptom-related qualify of life (QOL) and time spent on defecation. Despite its benefits, the insurance coverage for Peristeen depends on the pts specific insurance plan. Currently there is no Medicare benefit for the Peristeen, all claims are denied as non-covered with no Medicare benefit and separate billing for individual components is not allowed.We aimed to evaluate the insurance coverage for Peristeen amongst our neurogenic bowel pts referred to a tertiary care practice.
Methods: A retrospective, single-center, analysis (December 2019-March 2022) of 45 pts enrolled in Peristeen was performed. Variables within the prescription form include primary and secondary insurance coverage and diagnosis code. All diagnostic ICD 10 codes were Neurogenic Bowel, K59.2. One nurse completed all forms. The percentage of pts approved and denied by insurance type was reported in graphical form by creation of a two-by-six contingency table in SPSS after recording of data.
Results: Peristeen approval was significantly lower in pts insured with Medicare alone and with combined Medicare coverage compared to Private/Medicaid coverage. Approval percentages included 57% (Private 16/45), 0% (Medicare 0/45), 0% (No insurance 0/45), 11% (Medicaid 3/45), 29% (Medicare/Private 8/45), 3% (Medicare/Medicaid 1/45). Denial percentages included 12% (Private), 12% (Medicare 2/45), 6% (No insurance 1/45), 0% (Medicaid 0/45), 53% (Medicare/Private 9/45), 17% (Medicare/Medicaid 3/45).
Discussion: Few insurances provide coverage for Peristeen, despite the advantages it provides to a segment of society with a significant health burden from severe constipation and fecal incontinence. This study further bolsters the results needed for improvement in insurance coverage for a vulnerable population with healthcare disparities. Pts insured with Medicare and/or combined Medicare/Private insurance coverage have lower approval rates compared to pts with Medicaid and/or Private insurance alone. Future studies are needed to fully address the coverage and reimbursement for Peristeen, as lack of access to a successful bowel management program can result in poor clinical outcomes for pts with NBD.
Figure: Percentage of approval or denial of Peristeen transanal irrigation system by insurance type
