M1 prostate / denial of treatment by Evicore

[deleted1111261]

So, the Evicore guidelines say ...

You can treat per STAMPEDE in these scenarios

- meets low volume criteria BUT not by the standards of the study (i.e. they used bone scan which vastly under shows disease). In my case, the bone scan study showed limited disease. For whatever reason, a PSMA-PET was also ordered. Since that showed more disease than bone scan, this was considered high volume.

- must be castration naive. If they got a smidgen of ADT, they are not eligible for treatment

- must not be a candidate for Xtandi, Zytiga, etc. If they are a candidate for these drugs, then they CANNOT get RT to prostate. Which is a catch 22, b/c once they get these agents and ADT first, they are now NEVER candidates.

- you have to use 55 Gy in 20.

Extremely frustrating discussion. No understanding of the practicalities of medicine, oncologic principles, etc. Just "this is what the guidelines say". This is why PA should not have full time reviewers. They need a clinic. I can see the argument against allowing what I wanted to a point, but there are MANY other patients that are going to get denied that really would benefit from treatment.

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[ramsesthenice]

So, the Evicore guidelines say ...

You can treat per STAMPEDE in these scenarios

- meets low volume criteria BUT not by the standards of the study (i.e. they used bone scan which vastly under shows disease). In my case, the bone scan study showed limited disease. For whatever reason, a PSMA-PET was also ordered. Since that showed more disease than bone scan, this was considered high volume.

- must be castration naive. If they got a smidgen of ADT, they are not eligible for treatment

- must not be a candidate for Xtandi, Zytiga, etc. If they are a candidate for these drugs, then they CANNOT get RT to prostate. Which is a catch 22, b/c once they get these agents and ADT first, they are now NEVER candidates.

- you have to use 55 Gy in 20.

Extremely frustrating discussion. No understanding of the practicalities of medicine, oncologic principles, etc. Just "this is what the guidelines say". This is why PA should not have full time reviewers. They need a clinic. I can see the argument against allowing what I wanted to a point, but there are MANY other patients that are going to get denied that really would benefit from treatment.

I had a similar experience but was able to get it through with Evicore by having radiology addend the PET report to clearly state only 1 of the PET osseous lesions had associated sclerosis and was definitive for metastatic disease.

I’ve run into this a lot. It can be very frustrating.

 

[Mandelin Rain]

So, the Evicore guidelines say ...

You can treat per STAMPEDE in these scenarios

- meets low volume criteria BUT not by the standards of the study (i.e. they used bone scan which vastly under shows disease). In my case, the bone scan study showed limited disease. For whatever reason, a PSMA-PET was also ordered. Since that showed more disease than bone scan, this was considered high volume.

- must be castration naive. If they got a smidgen of ADT, they are not eligible for treatment

- must not be a candidate for Xtandi, Zytiga, etc. If they are a candidate for these drugs, then they CANNOT get RT to prostate. Which is a catch 22, b/c once they get these agents and ADT first, they are now NEVER candidates.

- you have to use 55 Gy in 20.

Extremely frustrating discussion. No understanding of the practicalities of medicine, oncologic principles, etc. Just "this is what the guidelines say". This is why PA should not have full time reviewers. They need a clinic. I can see the argument against allowing what I wanted to a point, but there are MANY other patients that are going to get denied that really would benefit from treatment.

It doesn’t matter if they have a clinic or not, for the purposes of UA, reviewers understand exactly what UHC tells them to understand. Always. Real Upton Sinclair situation.

 

[deleted1111261]

It doesn’t matter if they have a clinic or not, for the purposes of UA, reviewers understand exactly what UHC tells them to understand. Always. Real Upton Sinclair situation.

Maybe?
Idk. I think that’s the difference for us.

 

[TheWallnerus]

I think you have to be very

judicious

about the clinical information you choose to share with benefit management companies

E.g., in this case. PSMA results… so what? PSMA is not allowed to be used for staging by AJCC criteria. Don’t ask; sure as hell don’t tell.

 

[thesauce]

So, the Evicore guidelines say ...

You can treat per STAMPEDE in these scenarios

- meets low volume criteria BUT not by the standards of the study (i.e. they used bone scan which vastly under shows disease). In my case, the bone scan study showed limited disease. For whatever reason, a PSMA-PET was also ordered. Since that showed more disease than bone scan, this was considered high volume.

- must be castration naive. If they got a smidgen of ADT, they are not eligible for treatment

- must not be a candidate for Xtandi, Zytiga, etc. If they are a candidate for these drugs, then they CANNOT get RT to prostate. Which is a catch 22, b/c once they get these agents and ADT first, they are now NEVER candidates.

- you have to use 55 Gy in 20.

Extremely frustrating discussion. No understanding of the practicalities of medicine, oncologic principles, etc. Just "this is what the guidelines say". This is why PA should not have full time reviewers. They need a clinic. I can see the argument against allowing what I wanted to a point, but there are MANY other patients that are going to get denied that really would benefit from treatment.

They understand it. They just don’t want to pay.

I had one where they denied the RT saying “you need to shrink it down first with ADT before trying RT” Then the very next case, they said “RT can only be used if you haven’t used ADT”

 

[evilbooyaa]

So, the Evicore guidelines say ...

You can treat per STAMPEDE in these scenarios

- meets low volume criteria BUT not by the standards of the study (i.e. they used bone scan which vastly under shows disease). In my case, the bone scan study showed limited disease. For whatever reason, a PSMA-PET was also ordered. Since that showed more disease than bone scan, this was considered high volume.

- must be castration naive. If they got a smidgen of ADT, they are not eligible for treatment

- must not be a candidate for Xtandi, Zytiga, etc. If they are a candidate for these drugs, then they CANNOT get RT to prostate. Which is a catch 22, b/c once they get these agents and ADT first, they are now NEVER candidates.

- you have to use 55 Gy in 20.

Extremely frustrating discussion. No understanding of the practicalities of medicine, oncologic principles, etc. Just "this is what the guidelines say". This is why PA should not have full time reviewers. They need a clinic. I can see the argument against allowing what I wanted to a point, but there are MANY other patients that are going to get denied that really would benefit from treatment.

All of these are tools to avoid having to pay for medically necessary care. Threaten to document the p2p name and NPI in the chart stating that they are overriding your medical opinion.

There is now data for doing STAMPEDE even if high volume to lower risks of G3 acute urinary obstruction and subsequent hospitalization. Not saying that it should be a reason to give radiation in 100% of cases, but a scenario where it is reasonable based on clinical judgment to offer it.

H/o ADT and/or receipt of abiraterone continue to be the shady moves that only stand to benefit the insurance company and NOT the patient.

Only allowing 20Fx, I get, because I don't know it's worth treating non-oligomet patients with full definitive doses of radiation, especially if you're not then planning to ablate all gross disease...

 

[MidwestRadOnc]

Only allowing 20Fx, I get, because I don't know it's worth treating non-oligomet patients with full definitive doses of radiation, especially if you're not then planning to ablate all gross disease...

I see no reason, if you have an MRI or PET, not to dose paint gross disease to a true definitive dose (> 60 Gy/20 fx) and keep the rest of the gland and urethra cooler at trial dose.

 

[Reaganite]

It's so interesting to read these posts because in my neck of the woods almost everything gets approved. The insurers just don't pay on the back end.

 

[medgator]

It's so interesting to read these posts because in my neck of the woods almost everything gets approved. The insurers just don't pay on the back end.

Sounds like a great way to stay in business

 

[A_DeMichele]

All of these are tools to avoid having to pay for medically necessary care. Threaten to document the p2p name and NPI in the chart stating that they are overriding your medical opinion.

There is now data for doing STAMPEDE even if high volume to lower risks of G3 acute urinary obstruction and subsequent hospitalization. Not saying that it should be a reason to give radiation in 100% of cases, but a scenario where it is reasonable based on clinical judgment to offer it.

H/o ADT and/or receipt of abiraterone continue to be the shady moves that only stand to benefit the insurance company and NOT the patient.

Only allowing 20Fx, I get, because I don't know it's worth treating non-oligomet patients with full definitive doses of radiation, especially if you're not then planning to ablate all gross disease...

Regarding demanding the name and NPI... You always get a denial / approval letter authored by the RadOnc (ask your biller). NPI's are public (google yours). Lastly, it serves no good to document prior auth or MD squabbles in the patient's medical chart, that was like 1st thing we learned at the PGY1 orientation

 

[medgator]

Regarding demanding the name and NPI... You always get a denial / approval letter authored by the RadOnc (ask your biller). NPI's are public (google yours). Lastly, it serves no good to document prior auth or MD squabbles in the patient's medical chart, that was like 1st thing we learned at the PGY1 orientation

At least we know who the resident Evilcore shill is on the forum

 

[RickyScott]

In many cases, reviewing radonc is bound by the policy and does not have power to approve a treatment even if he agrees with it. Not sure how listing npi etc would help.

 

[Palex80]

So, the Evicore guidelines say ...


- you have to use 55 Gy in 20.

Why not 6 x 6 Gy, weekly?

 

[TheWallnerus]

Why not 6 x 6 Gy, weekly?

They should allow that

They will not allow 5 fractions

 

[deleted1111261]

Doesn’t do a thing, but I always agree with them when they threaten to!

(Am I shilling against myself??)

 

[A_DeMichele]

probably OK to threaten an Evicore or other benefit management company employee... Be more careful verbally abusing BCBS or UHC people - your University employer has a legal obligation to insurance companies to enforce good behavior

 

[evilbooyaa]

Regarding demanding the name and NPI... You always get a denial / approval letter authored by the RadOnc (ask your biller). NPI's are public (google yours). Lastly, it serves no good to document prior auth or MD squabbles in the patient's medical chart, that was like 1st thing we learned at the PGY1 orientation

I was told don't 'fight' in the chart amongst other practitioner's (physicians, NPs, PAs, nursing, etc.) within the VUMC system. Nothing against naming and shaming EviCore reviewers.

Lots of folks out there with similar names to other doctors out there. Not all RO reviewers are ROs!

 

[evilbooyaa]

probably OK to threaten an Evicore or other benefit management company employee... Be more careful verbally abusing BCBS or UHC people - your University employer has a legal obligation to insurance companies to enforce good behavior

BCBS and UHC farm out their RO stuff to EviCore anyways, don't they? I don't think I've ever spoken to a RO employed direclty by BCBS or EviCore. Always some URM intermediary... EviCore, AIM, etc. etc.

 

[ramsesthenice]

UA aside, I’m at the point I’ve tried to get our urologists to be a bit more careful about reflexively getting PYL scans for all, particularly intermediate risk patients. I’ve had a few of these where CT and BS were negative with nothing indeterminate yet a PYL scan was done and found the ambiguous “focal moderate uptake in X rib concerning for possible metastasis”. In addition to causing insurance issues, these folks sometimes end up on long term ADT with Zytiga which they probably don’t actually need.

One thing I have had luck with is having the reading radiologist specifically say if there is no associated sclerosis or CT correlate, the lesion remains indeterminate.

 

[Palex80]

They should allow that

They will not allow 5 fractions

Would it not be cheaper than 20 x 2.75 Gy?

 

[Chartreuse Wombat]

Would it not be cheaper than 20 x 2.75 Gy?

Not in the US. 5 or less gets SBRT management code

 

[Palex80]

Not in the US. 5 or less gets SBRT management code

Well, that's why I said 6 fractions. 6 x 6 Gy was one of the two STAMPEDE schedules.

 

[drowsy12]

Not in the US. 5 or less gets SBRT management code

that is a choice one makes.

you can easily bill and charge for 5 fraction IMRT if you wish.

 

[evilbooyaa]

UA aside, I’m at the point I’ve tried to get our urologists to be a bit more careful about reflexively getting PYL scans for all, particularly intermediate risk patients. I’ve had a few of these where CT and BS were negative with nothing indeterminate yet a PYL scan was done and found the ambiguous “focal moderate uptake in X rib concerning for possible metastasis”. In addition to causing insurance issues, these folks sometimes end up on long term ADT with Zytiga which they probably don’t actually need.

One thing I have had luck with is having the reading radiologist specifically say if there is no associated sclerosis or CT correlate, the lesion remains indeterminate.

Isolated Rib lesions on PYL scan, especially for a IR patient, should be getting biopsy confirmation 100% of the time if the plan is to treat as metastatic. Lots of false positives in Ribs, especially with lower SUVs, doubly so if no CT correlate.

I do this for all PSMA PETs who have avidity in bone without CT correlate: Get a MRI of area, which is better than CT. If MRI positive for potentially malignant condition (sometimes Rads feels confident is say a hemangioma in the spine or something), pursue biopsy. I've had 1 out of 10 or so patients in this space end up with a biopsy, which was positive.

At this point, PSMA uptake in rib without CT correlate gets ignored at my institution with recommendations for 'monitoring on follow-up' that never happens assuming otherwise appropriate PSA response.

 

[neo87]

One strategy that is tedious but has worked for me - our state dept of insurance has a mechanism which forces external review of insurance denials - I have had patients file a complaint with the state and have rarely had the state force the insurer to cover the treatment... FWIW not something you can do routinely but just making people aware there may be a way to "go above" the insurance company in extreme situations.

 

[SneakyBooger]

One strategy that is tedious but has worked for me - our state dept of insurance has a mechanism which forces external review of insurance denials - I have had patients file a complaint with the state and have rarely had the state force the insurer to cover the treatment... FWIW not something you can do routinely but just making people aware there may be a way to "go above" the insurance company in extreme situations.

I do this with standard fractionation for prostate.

However, I haven't had a patient who has gotten to that point. The Corporation approves standard fractionation before it goes to the state.

Ignore the peer to peer. Go straight to appeal with a well written letter - a letter a judge or a lawyer (and the patient) can easily use.

Refer to the insurer as "The Corporation".

Regarding fractionation in M1 prostate ca, the currently enrolling SWOG S1802 protocol states standard fractionation is an appropriate option. Hypofractionation is for countries with 3rd world medical care (UK, Canada, etc).

 

[drowsy12]

‘Hypofractionation is for countries with 3rd world medical care (UK, Canada, etc).’


That’s certainly a take

 

[MidwestRadOnc]

I do this with standard fractionation for prostate.

However, I haven't had a patient who has gotten to that point. The Corporation approves standard fractionation before it goes to the state.

Ignore the peer to peer. Go straight to appeal with a well written letter - a letter a judge or a lawyer (and the patient) can easily use.

Refer to the insurer as "The Corporation".

Regarding fractionation in M1 prostate ca, the currently enrolling SWOG S1802 protocol states standard fractionation is an appropriate option. Hypofractionation is for countries with 3rd world medical care (UK, Canada, etc).

Do you do your own billing and collections?
This is one of the (small) handful of advantages of being employed or a fixed rate contractor.
It's not your problem on the backend. You do what's right for the patient and treat.
UHC seems to think they have this trick figured out though. I'm not sure how/why this is legal, not being able to appeal after the fact.
The time suck involved in what you are describing sounds exhausting.

 

[grenz]

Had a new one today (United of course). United didn’t have a peer reviewer available for a whole week. She started right off and said United doesn’t cover IMRT for X condition, and the purpose of this call is for her to document why I was requesting IMRT for the medical director to review if I appealed.

Reeked of total bull. They could have just had me submit a LOMN a week ago if all they needed was documentation of my rationale. Just a delay tactic that is now delaying her care. Does anyone know who I can complain to about this new tactic?

 

[Mandelin Rain]

Had a new one today (United of course). United didn’t have a peer reviewer available for a whole week. She started right off and said United doesn’t cover IMRT for X condition, and the purpose of this call is for her to document why I was requesting IMRT for the medical director to review if I appealed.

Reeked of total bull. They could have just had me submit a LOMN a week ago if all they needed was documentation of my rationale. Just a delay tactic that is now delaying her care. Does anyone know who I can complain to about this new tactic?

Not a new tactic. p2p has becomes less and less useful in getting anything accomplished. Just a time suck.

 

[grenz]

Not a new tactic. p2p has becomes less and less useful in getting anything accomplished. Just a time suck.

They’ve said for a while that they’re powerless to approve, but this new bogus justification that the purpose is for documentation was deceptive.

 

[Mandelin Rain]

They’ve said for a while that they’re powerless to approve, but this new bogus justification that the purpose is for documentation was deceptive.

True. I've heard the former many times, the latter would indeed be new to me.

 

[TheWallnerus]

In my case, the bone scan study showed limited disease. For whatever reason, a PSMA-PET was also ordered. Since that showed more disease than bone scan, this was considered high volume.

In reviewing Mel Gibson's 'The Passion of the Christ,' Roger Ebert made a point that anyone who says that the Jews killed Jesus violates their own beliefs:

A reasonable person, I believe, will reflect that in this story set in a Jewish land, there are many characters with many motives, some good, some not, each one representing himself, none representing his religion. The story involves a Jew who tried no less than to replace the established religion and set himself up as the Messiah. He was understandably greeted with a jaundiced eye by the Jewish establishment while at the same time finding his support, his disciples and the founders of his church entirely among his fellow Jews. The libel that the Jews "killed Christ" involves a willful misreading of testament and teaching: Jesus was made man and came to Earth in order to suffer and die in reparation for our sins. No race, no man, no priest, no governor, no executioner killed Jesus; he died by God's will to fulfill his purpose, and with our sins we all killed him. That some Christian churches have historically been guilty of the sin of anti-Semitism is undeniable, but in committing it they violated their own beliefs.

If a payor (or rad onc!) cites STAMPEDE but then uses PSMA-PET results to assess metastatic burden, that payor (or rad onc!) is just as logically inconsistent as an anti-Semitic Christian. (Yes, I'm making tons of religious references today for whatever reason.)

 

[seper]

One strategy that is tedious but has worked for me - our state dept of insurance has a mechanism which forces external review of insurance denials - I have had patients file a complaint with the state and have rarely had the state force the insurer to cover the treatment... FWIW not something you can do routinely but just making people aware there may be a way to "go above" the insurance company in extreme situations.

Time is not on your side, if you choose that approach

 

[metallica81788]

Had a new one today (United of course). United didn’t have a peer reviewer available for a whole week. She started right off and said United doesn’t cover IMRT for X condition, and the purpose of this call is for her to document why I was requesting IMRT for the medical director to review if I appealed.

Reeked of total bull. They could have just had me submit a LOMN a week ago if all they needed was documentation of my rationale. Just a delay tactic that is now delaying her care. Does anyone know who I can complain to about this new tactic?

Maybe we had the same reviewer, had one for a rectal case last week. Immediately said couldn't approve and would have to appeal but that there was a high success rate. I had already submitted 3D comparisons so there wasn't anything left for me to do besides send the appeal.

I was out for a few days and returned to the appeal already being approved and patient starting. Annoying for sure, but I've had worse experiences.

 

[MidwestRadOnc]

Time is not on your side, if you choose that approach

I've went through this process before. Was told it would be about 6 months to get this legally adjudicated after appeal was denied (SBRT for solitary liver met). Practice took the hit and treated for free finally after a few months of back and forth. If anybody has a story of getting appeals overturned by the state and forcing the insurance company to authorize, I would love to hear it.

 

[RickyScott]

Maybe we had the same reviewer, had one for a rectal case last week. Immediately said couldn't approve and would have to appeal but that there was a high success rate. I had already submitted 3D comparisons so there wasn't anything left for me to do besides send the appeal.

I was out for a few days and returned to the appeal already being approved and patient starting. Annoying for sure, but I've had worse experiences.

Judy samuels?

 

[NotMattSpraker]

Judy samuels?

The hair on the back of my neck stood up when I was in clinic a bit ago and I guess now I know why.

Dont say the name 2 more times!

 

[evilbooyaa]

Had a new one today (United of course). United didn’t have a peer reviewer available for a whole week. She started right off and said United doesn’t cover IMRT for X condition, and the purpose of this call is for her to document why I was requesting IMRT for the medical director to review if I appealed.

Reeked of total bull. They could have just had me submit a LOMN a week ago if all they needed was documentation of my rationale. Just a delay tactic that is now delaying her care. Does anyone know who I can complain to about this new tactic?

Report to state insurance commissioner. I have personally done it > 10 times over the past 1-2 years and, anecdotally, feel like I have to deal with less p2ps and denials than I used to.

I haven't had to do p2ps on stuff that I would have had to do like 3 years ago.... and that's without any significant increase in evidence of what I'm doing (oligoprogressive dz management in non-lung cancer)

 

[HolySmokes]

The hair on the back of my neck stood up when I was in clinic a bit ago and I guess now I know why.

Dont say the name 2 more times!

Just had my first experience with this infamous reviewer. 2/10 would not recommend.