Is HIFU Covered by Insurance?
Insurance Company Coverage and Reimbursement for HIFU
Medicare patients please click here to learn more about Medicare coverage of HIFU as of July 2017
For virtually all patients, there is typically no coverage by commercial health insurers, or Medicare for HIFU at this time. While Medicare did cover a substantial part of the HIFU cost from mid-2017 to the end of 2018, that is no longer the case. (Beware of medical practices that tell you Medicare will cover your procedure!) At Western States HIFU, we have our all-inclusive price for a HIFU procedure, including surgery center facility fees, the HIFU physician charge, anesthesiologist fees, and charges by the HIFU Prostate Services for your pre- and post-HIFU care. The total amount for all of this is $25,000. We do not add undisclosed pre- or post-HIFU fees. Our price is all inclusive.
While you can certainly request that your HIFU procedure be pre-authorized by your insurance plan, this is typically not possible because HIFU does not have a “CPT” code. Because of this, there is usually no mechanism that allows for insurance company coverage. Occasionally, you can get retroactive reimbursement. This means that, after your HIFU procedure has been performed, you can request reimbursement from your insurer. This may be a cumbersome process that requires going through a series of appeals to the insurance plan. We are able to assist you by providing a letter justifying your HIFU procedure. We do this without charge.
In addition, there are companies that may assist you in appealing a payment denial by your insurer. They typically charge a fee of approximately 15%. While we do not have any direct relationship to these companies, HIFU Prostate Services can give you the appropriate contact information.
Be Careful of Practices or Institutions That Tell Your HIFU Procedure Will be Covered by Your Insurance Plan!
This is not true. It is typically stated by doctors or facilities who are just starting to perform HIFU and have little or no experience with patient insurance issues. Dr. Pugach has been performing HIFU for 14 years. He is one of most experienced HIFU practitioner in the world. Based on this experience, you can trust the information we give you. Some practices may lead you to believe your insurance plan will pre-authorize your procedure or definitely pay for it afterward. This is not true so be sure you do not find yourself in an uncomfortable financial situation after or just before your procedure!
Other HIFU-Related Expenses
Your initial consultation with Dr. Pugach may be covered by your insurance plan. We are happy to check your benefits without charge. Just call, 844.443.8362 so we can verify your insurance.
The cost of pre-HIFU medical clearance and any lab tests required by your anesthesiologist are not included in any HIFU fees. We will outline all of this for you in detail so there are no unforeseen financial surprises. The cost of this testing is usually very nominal.
We understand that HIFU is an expensive procedure. Unlike some other treatments for prostate cancer, it is not yet covered by insurance. That is because it typically takes about 5 years from FDA approval of a procedure to the time when insurers pay for it. For HIFU, that means insurance will likely begin very limited coverage in 2021.
If you have been diagnosed with cancer of the prostate, and want to avoid the side effects of surgery or recurrence rates after radiation, HIFU is often the best option. It was for Dr. Robert Pugach when he invested in his future health and had a HIFU procedure himself in 2017. (Read his story here). We are happy to help you evaluate the cost of HIFU and its safety profile when you have your in person, online, or telephone consultation.
Please call to discuss financial arrangements and further financing options.
Please call (844) 442-8362 to discuss the cost of HIFU, financial arrangements and financing options available with HIFU Prostate Services. (Attention: If you are Medicare patient, learn more about financial coverage available through Medicare for HIFU).
At Western States HIFU, we work closely with HIFU Prostate Services, LLC (the country’s most experienced HIFU provider) to streamline the entire process including payment processing. HPS has reimbursement specialists standing by to assist you without charge.
Additional Medical and Laboratory Information
We’re here to help you. Providing your clinical information to us facilitates that and minimizes duplication of tests that increase your costs unnecessarily. While every patient’s medical information varies, there are certain items that help us determine if HIFU may be an appropriate treatment option for you. The most important medical information and laboratory tests you can provide are:
- Pathology report from your biopsy
- PSA results – actual lab slips going back as far as you can find them
- Copies of the ultrasound images that were made when you had your biopsy
- MRI report(s), if you’ve had one done
- Bone scan results, if you’ve had one done
- Copies of office records from your urologist
- Copies of reports from any consultants you’ve seen
If you are in the greater Los Angeles and Orange County area, or surrounding communities, we offer convenient appointments in our two private practice offices in Los Alamitos and Huntington Beach. We typically schedule appointments at the end of each day so you won’t feel rushed as we discuss your prostate cancer and treatment options
For patients who live in more distant areas of California, neighboring states, other parts of the U.S., or if you are an international patient, Dr. Robert Pugach offers online/virtual or telephone consultations in a time zone that is mutually convenient.