“Since January 1, we haven’t been paid for these procedures,” said Dr. Elliot Adams, a vascular surgeon whose office-based lab treats patients with advanced peripheral artery disease. “These are very costly interventions, and we simply can’t remain solvent for long if reimbursement doesn’t come through.”
That warning, delivered during a recent episode of The Heart of Innovation, underscores a growing concern among vascular specialists nationwide: a Medicare billing issue that could sharply curtail access to limb-saving care for patients with one of the deadliest and most under-recognized vascular diseases in the country.
The discussion took place on The Heart of Innovation, which I host, with guest co-host Dr. Todd Berland, a vascular surgeon and host of The Vascular Surgery Show on SiriusXM Doctor Radio. Joining us were Dr. Elliot Adams and Dr. Bob Tahara, past president of the Outpatient Endovascular and Interventional Society (OEIS), who has spent years working with Medicare on coverage and reimbursement issues affecting vascular care.
At the center of the issue are newly implemented CPT codes that went into effect January 1, designed to better reflect the complexity of modern peripheral artery disease interventions. Older codes were retired and replaced with a structure that differentiates less severe disease from chronic total occlusions, procedures that often require advanced tools, longer procedure times, and substantially higher costs. Medicare has already valued these services within the physician fee schedule.
Despite that, physicians report that claims submitted correctly under the new codes are being denied when procedures are performed in office-based labs across states administered by Medicare contractors Noridian and Novitas.
Peripheral artery disease, or PAD, is often misunderstood as a condition of discomfort rather than danger. In reality, it is a progressive vascular disease that affects millions of Americans and is closely linked to heart attack, stroke, and premature death. An estimated three in five people who suffer a heart attack also have PAD, frequently without knowing it. In advanced stages, PAD carries a mortality risk that rivals or exceeds that of many common cancers. When circulation becomes critically compromised, patients develop severe ischemic pain, non-healing wounds, and tissue loss. Delay care, and the likelihood of amputation rises sharply.
Office-based labs have transformed how these patients are treated.
By allowing vascular specialists to perform complex revascularization procedures outside the hospital setting, physicians have expanded access to care, particularly in rural and underserved areas, shortened wait times, and reduced amputation rates. In many communities, these labs are not a convenience; they are the only timely access point for advanced limb-salvage care.
That model, however, depends on reimbursement that covers the cost of treatment. Unlike hospital-based care, physicians operating office-based labs are financially responsible for every component of the procedure. As Dr. Tahara explained during the broadcast,
“When you treat patients in an office-based facility, the physician is responsible for every wire, every stent, every atherectomy device, every lithotripsy catheter, every supply. Reimbursement isn’t profit. It’s what allows the care to happen at all.”
For Dr. Adams, the consequences of nonpayment are already tangible. Since January 1, his practice has received no reimbursement for procedures billed under the new CPT codes.
“For doctors to not get paid for these procedures is a big, big problem,” he said. “We front the cost of everything.”
In rural regions, the implications extend well beyond individual practices. Dr. Adams described the impact his office-based lab has had on patient outcomes in his area.
“Before we opened our lab, we were seeing close to 100 amputations a year,” he said. “Afterward, that number dropped to around 20. If these labs close or have to cut back, those numbers are going to go back up.”
During the discussion, concerns were raised that denials may be extending beyond office-based labs into ambulatory surgery centers, with contractors citing site-of-service issues. Dr. Tahara addressed that explanation by pointing out that Medicare has already established valuation for these services across care settings, making prolonged nonpayment difficult to reconcile with existing policy.
Compounding the uncertainty is a lack of clear communication. When contacted for comment, Noridian referred inquiries to Medicare. Medicare indicated a response would be provided within 24 to 48 hours. As of airtime, no response had been received.
Dr. Tahara cautioned against assuming intent, emphasizing instead the complexity of Medicare’s administrative structure. Still, he warned that delay itself carries serious consequences.
“This is only sustainable for a couple of months at best,” he said. “Practices cannot continue to front the cost of care indefinitely.”
He drew a direct parallel to what is already occurring under Medicare Advantage plans, which he has pointedly referred to as “Medicare disadvantage.” Prior authorizations and peer-to-peer reviews routinely delay time-sensitive vascular care.
“Just like what we’re seeing with Medicare (dis)Advantage plans that delay and deny procedures, doctors will be forced to cut back on their procedure schedules,” he said. “And when that happens, more patients end up with amputations.”
During the discussion, I shared an example that illustrates the stakes.
A patient with limb-threatening disease was denied revascularization following a peer-to-peer review conducted by a physician outside the vascular specialty, an OBGYN. The patient ultimately presented to the emergency department and underwent amputation rather than limb salvage.
Reimbursement Uncertainty Will Lead To Office Shutdowns & Amputations
If reimbursement uncertainty forces office-based labs to scale back services or shut down altogether, the burden will shift to hospitals that are already operating at capacity.
Wait times will increase.
Disease will progress.
Amputation rates will rise.
Ironically, amputations themselves are rarely questioned or delayed by payers, despite their lifelong cost to patients and the healthcare system.
Insurance companies cover amputations cart blanche without question.
Whether the current situation represents a temporary implementation failure or a broader shift in how limb-salvage care is delivered remains unresolved. What is clear is that peripheral artery disease does not pause while reimbursement questions are sorted out.
Physicians are acting in good faith to support these patients.
They continue to treat patients, absorbing financial risk in the hope that clarity will come quickly.
Advocacy organizations and professional societies are escalating the issue within Medicare, and Dr. Tahara is scheduled to address reimbursement concerns at an upcoming congressional PAD caucus. But if a government shuts down again, and Dr. Tahara doesn’t have a chance to address Congress, we could see a dramatic increase in amputations over the next three months.
Dr. Tahara asked during the discussion for patients to reach out to their state representatives to help address the situation urgently. He also suggested that if patients receive a notice from Medicare indicating it will not cover a limb-saving procedure, they share it immediately with the treating physician’s office. Many denials, he explained, can be challenged, but only if clinicians are made aware of them.
At the same time, Dr. Tahara emphasized that physicians and professional societies are working urgently to resolve the issue before it reaches patients, before denial letters go out, and before further limb-saving care is disrupted.
In vascular disease, time is tissue.
All of the physicians on the panel agreed that these Medicare denials cannot be ignored and must be addressed immediately.
By the time the consequences surface, they are no longer measured in policy or process, but in amputations that could have been prevented.
🚨 If you are a physician, clinician, or billing professional seeing these denials, we want to hear from you.
🚨 If you are a patient who has received a Medicare denial or delay for PAD care, your story matters.
📞 Leg Saver Hotline: 1-833-PAD-LEGS
🌐 Patient education & support: www.PADhelp.org
🎧 More episodes: www.TheHeartofInnovation.org
