Palmetto/CMS/LCD not covering R sided IMRT APBI

[BobbyHeenan]

Has anyone else seen this?

I'm seeing that in spite of NCCN saying 30/5 IMRT is the preferred APBI approach, Palmetto (the LCD for a huge chunk of the country) is not covering IMRT even for APBI in R sided breast cases.

Is this correct?
Is this something that is amenable to any appeals?

Absolutely insane that a relatively cheap treatment, proven in a phase 3 trial, listed in NCCN guidelines as the preferred technique/fractionation....is not paid for by cms.

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Members don't see this ad.

 

[OTN]

Insane. Media pressure likely would be the only way to turn this around. ASTRO? Are you listening?

 

[drowsy12]

https://x.com/DrAntoParavati/status/1752533095734026267?s=20

https://x.com/DrAntoParavati/status/1752535894408548405?s=20

 

[Mandelin Rain]

It's literally "per protocol" treatment.

 

[BobbyHeenan]

https://x.com/DrAntoParavati/status/1752533095734026267?s=20

https://x.com/DrAntoParavati/status/1752535894408548405?s=20

I saw that.

In the mean time I guess I'll just give sub standard care. What a mess.

 

[MidwestRadOnc]

It's literally "per protocol" treatment.

Do you think they care?

I've treated with an SIB RTOG 1005 style a few times. And I've also treated whole breast in 5 fractions with 26 Gy to the breast and 30 Gy to the cavity.

I was told in both instances that I was practicing "experimental medicine" by using IMRT for an SIB and was forced to deliver a daily 3D boost instead. This was far less conformal and the patients had worse acute toxicity and cosmetic outcome. When I have been allowed to deliver SIB with IMRT there have been zero issues. Beautiful plans vs. splaying boost dose well beyond boost volume.

ASTRO? Are you listening?

What do you think? They care about the struggles of independent rad oncs? They want you to be employed as part of large systems and until this kind of nonsense ends, what's the incentive of going out on your own vs. let someone else deal with it and collect a salary?

 

[drowsy12]

https://x.com/drantoparavati/status/1752716417164530031?s=46&t=rlNDSubO1Ki87D_HsF0Yvg

Interesting regarding Medicare advantage

 

[medgator]

Insane. Media pressure likely would be the only way to turn this around. ASTRO? Are you listening?

Don't you know... Choose wisely and don't choose imrt for breast cancer duh!! (Refer to your nearest proton center if necessary)

 

[medgator]

https://x.com/drantoparavati/status/1752716417164530031?s=46&t=rlNDSubO1Ki87D_HsF0Yvg

Interesting regarding Medicare advantage

Well known issues. MA is hot garbage that is great for lining the pockets of uhc, cigna, Humana shareholders and management

 

[MidwestRadOnc]

Well known issues. MA is hot garbage that is great for lining the pockets of uhc, cigna, Humana shareholders and management

I don't think I can remember the last time I saw a pure medicare patient and now it seems many medicaid patients are being managed by these companies which now means PA for medicaid patients!

 

[drowsy12]

I’ve been dealing with PA for Medicaid for years. Few things scare me more, those guys and gals don’t give an inch.

 

[Mandelin Rain]

I’ve been dealing with PA for Medicaid for years. Few things scare me more, those guys and gals don’t give an inch.

Straight Medicaid PA? Never heard of that.

 

[MidwestRadOnc]

Straight Medicaid PA? Never heard of that.

Lucky you. I'm assuming it's only certain states allowing this/outsourcing their medicaid management.

Oklahoma firm claims out-of-state groups get special treatment to secure Medicaid contracts

Oklahoma’s attempt to outsource the management of its Medicaid program is again being challenged, this time by a local health care organization.

www.oklahoman.com

The governor believes private companies will have an incentive to improve health care if profits are on the line.

Your Turn: Outsourcing the state's Medicaid program would also hurt nurses

Your Turn: Outsourcing the state's Medicaid program would also hurt nurses

www.oklahoman.com

These middlemen immediately begin rejecting and delaying claims for necessary services. Otherwise, Medicaid administration isn’t profitable for them.

Play stupid games, win stupid prizes.

 

[TheWallnerus]

For I, the Lord your God, am a jealous God, visiting the iniquity of the fathers upon the children to the third and fourth generations of those who hate Me.
- The Bible, Deuteronomy 5:9

 

[BobbyHeenan]

I believe in addition to this R sided breast fiasco... bone mets (C79.51) and Soft tissue (C49.x) sarcomas are also considered not covered for IMRT.

I *think* htere may be a carve out for SBRT for bone mets though.

 

[OTN]

View attachment 381862

For I, the Lord your God, am a jealous God, visiting the iniquity of the fathers upon the children to the third and fourth generations of those who hate Me.
- The Bible, Deuteronomy 5:9

"Recommendations" from our societies have been nothing but damaging to the field. I wish they would stop. I'm not holding my breath.

 

[NotMattSpraker]

View attachment 381862

For I, the Lord your God, am a jealous God, visiting the iniquity of the fathers upon the children to the third and fourth generations of those who hate Me.
- The Bible, Deuteronomy 5:9

ASTRO is harming women on this niche issue and I wish more radiation oncologists were outspoken about it.

A layer of wtf is added by the fact that prostate gets IMRT and there is no debate. You'd think the gender equity folks would be outraged but I guess representation of women physicians in movies is more important.

 

[NotMattSpraker]

I believe in addition to this R sided breast fiasco... bone mets (C79.51) and Soft tissue (C49.x) sarcomas are also considered not covered for IMRT.

I *think* htere may be a carve out for SBRT for bone mets though.

Soft tissue sarcomas are covered. ASTRO and the MSTS has said IMRT is standard for all cases. I haven't heard of insurance pushing back on this in a while, but if they do just give them the guideline. Should be enough for approval.

You should additionally be able to do the 5 fractions with no issue, but YMMV if you try to bill it as SBRT. I did not do this in my practice, but I know a couple of the prominent centers call it SBRT.

 

[Mandelin Rain]

ASTRO is harming women on this niche issue and I wish more radiation oncologists were outspoken about it.

A layer of wtf is added by the fact that prostate gets IMRT and there is no debate. You'd think the gender equity folks would be outraged but I guess representation of women physicians in movies is more important.

To be fair, they did recommend hypofractionated regimens for prostate despite that also harming men.

ASTRO is an equal opportunity harmer.

 

[BobbyHeenan]

Soft tissue sarcomas are covered. ASTRO and the MSTS has said IMRT is standard for all cases. I haven't heard of insurance pushing back on this in a while, but if they do just give them the guideline. Should be enough for approval.

You should additionally be able to do the 5 fractions with no issue, but YMMV if you try to bill it as SBRT. I did not do this in my practice, but I know a couple of the prominent centers call it SBRT.

Are you sure it's covered for Palmetto as the LCD for CMS? I'm pretty sure they took it out.
I'll try to look it back up and post a link if I find one. I hope I'm wrong.

 

[seper]

What is Palmetto? Does anyone have a link to their document?

 

[NotMattSpraker]

Are you sure it's covered for Palmetto as the LCD for CMS? I'm pretty sure they took it out.
I'll try to look it back up and post a link if I find one. I hope I'm wrong.

Oh, no I am not sure, that is a good point and more important. Sorry. I forgot we are talking Palmetto not medicine haha.

 

[MidwestRadOnc]

ASTRO is harming women on this niche issue and I wish more radiation oncologists were outspoken about it.

A layer of wtf is added by the fact that prostate gets IMRT and there is no debate. You'd think the gender equity folks would be outraged but I guess representation of women physicians in movies is more important.

What about pay equity?
I don't have the numbers to back this up, but empirical observation suggests academic breast rad oncs tend to be female and prostate rad oncs tend to be male.

So you are getting mostly 5-20 fractions of 3D vs. 28-45 fractions of IMRT + SBRT + procedures. That's umm, what... half the RVUs?
Is prostate much harder or time consuming to treat than breast?

 

[drowsy12]

What about pay equity?
I don't have the numbers to back this up, but empirical observation suggests academic breast rad oncs tend to be female and prostate rad oncs tend to be male.

So you are getting mostly 5-20 fractions of 3D vs. 28-45 fractions of IMRT + SBRT + procedures. That's umm, what... half the RVUs?
Is prostate much harder or time consuming to treat than breast?

you sure you want to bark this tree up? CMS would love to 'even things out'

 

[NotMattSpraker]

What about pay equity?
I don't have the numbers to back this up, but empirical observation suggests academic breast rad oncs tend to be female and prostate rad oncs tend to be male.

So you are getting mostly 5-20 fractions of 3D vs. 28-45 fractions of IMRT + SBRT + procedures. That's umm, what... half the RVUs?
Is prostate much harder or time consuming to treat than breast?

Haha, so that's been studied kind of recently. I wrote the authors and asked for the raw data since data sharing would be in line with Advances publishing policy. The SCAROP wage-fixing policy seems to supersede the Advances data sharing policy though, so they said no

My anecdotal take based on reviewing SCAROP surveys over time is that there may have been a gender disparity 5-10 years ago, but that is no longer true. Also, the average academic radiation oncologist is probably too slow for a RVU production bonus.

This paper seems to validate those anecdotes.

 

[BobbyHeenan]

Oh, no I am not sure, that is a good point and more important. Sorry. I forgot we are talking Palmetto not medicine haha.

Unfortunately I don't see the sarcoma codes in their listed codes for medical necessity for IMRT. I *think* this is a Palmetto issue, not a nationwide thing...which is insane.

Article - Billing and Coding: Radiation Therapies (A59350)

Use this page to view details for the Local Coverage Article for Billing and Coding: Radiation Therapies.

www.cms.gov

 

[BobbyHeenan]

What is Palmetto? Does anyone have a link to their document?

Someone please correct me if I'm mis stating, but as I understand it....Palmetto is the local coverage determination (LCD) company that helps administer/determine CMS payments and appropriate use for certain states/regions of the country. I just stumbled upon this when looking at twitter and reading Mudit Choudhary's post and toook a deep dive on it....

So while for instance IMRT R breast APBI may be paid for by medicare in California, if you're in Georgia right now it is not getting paid for because Palmetto is saying it is not a covered diagnosis that meets criteria for IMRT.

Below is a link to listed ICD 10 codes that do meet...

Article - Billing and Coding: Radiation Therapies (A59350)

Use this page to view details for the Local Coverage Article for Billing and Coding: Radiation Therapies.

www.cms.gov

 

[metallica81788]

That is absolutely insane

So ... why is this the case? How where you live determines these things?

 

[NotMattSpraker]

Someone please correct me if I'm mis stating, but as I understand it....Palmetto is the local coverage determination (LCD) company that helps administer/determine CMS payments and appropriate use for certain states/regions of the country. I just stumbled upon this when looking at twitter and reading Mudit Choudhary's post and toook a deep dive on it....

So while for instance IMRT R breast APBI may be paid for by medicare in California, if you're in Georgia right now it is not getting paid for because Palmetto is saying it is not a covered diagnosis that meets criteria for IMRT.

Below is a link to listed ICD 10 codes that do meet...

Article - Billing and Coding: Radiation Therapies (A59350)

Use this page to view details for the Local Coverage Article for Billing and Coding: Radiation Therapies.

www.cms.gov

It sounds like right breast IMRT APBI should be removed from ROCR since there is no consistent national payment rate.

 

[TheWallnerus]

Someone please correct me if I'm mis stating, but as I understand it....Palmetto is the local coverage determination (LCD) company that helps administer/determine CMS payments and appropriate use for certain states/regions of the country. I just stumbled upon this when looking at twitter and reading Mudit Choudhary's post and toook a deep dive on it....

So while for instance IMRT R breast APBI may be paid for by medicare in California, if you're in Georgia right now it is not getting paid for because Palmetto is saying it is not a covered diagnosis that meets criteria for IMRT.

Below is a link to listed ICD 10 codes that do meet...

Article - Billing and Coding: Radiation Therapies (A59350)

Use this page to view details for the Local Coverage Article for Billing and Coding: Radiation Therapies.

www.cms.gov

You’re correct

Wild how many rad oncs are completely oblivious to this… base reality (no judgment!)

 

[BobbyHeenan]

It sounds like right breast IMRT APBI should be removed from ROCR since there is no consistent national payment rate.

Ha .

I’m sure CMS will pay attention when ASTRo complains about it since ASTRO is really overall very reasonable on their coverage positions. I mean just look at the Astro proton coverage paper where they suggest every curative case should get paid for protons.

 

[RadRadRad]

Choosing Wisely just another radiation disaster
-don’t do Imrt while we are doing protons
-10 years later. Never mind ok to do Imrt

-don’t treat women over 70 even though multiple randomized trials show local control benefit (9-10% down to 1-2%) and the toxicity is near nil with 5 fx pbi. Meanwhile surgical choosing wisely is don’t do sln biopsy which has <1% regional control benefit . How great it must be to have your choosing wisely recs literally have no effect on patient outcome. Our choosing wisely should be don’t do regional nodal radiation for stage 1 luminal a breast cancer. That would be the equivalent

 

[evilbooyaa]

Choosing Wisely just another radiation disaster
-don’t do Imrt while we are doing protons
-10 years later. Never mind ok to do Imrt

-don’t treat women over 70 even though multiple randomized trials show local control benefit (9-10% down to 1-2%) and the toxicity is near nil with 5 fx pbi. Meanwhile surgical choosing wisely is don’t do sln biopsy which has <1% regional control benefit . How great it must be to have your choosing wisely recs literally have no effect on patient outcome. Our choosing wisely should be don’t do regional nodal radiation for stage 1 luminal a breast cancer. That would be the equivalent

Don't treat nodes for low or favorable intermediate risk prostate cancer

 

[NotMattSpraker]

Choosing Wisely just another radiation disaster
-don’t do Imrt while we are doing protons
-10 years later. Never mind ok to do Imrt

-don’t treat women over 70 even though multiple randomized trials show local control benefit (9-10% down to 1-2%) and the toxicity is near nil with 5 fx pbi. Meanwhile surgical choosing wisely is don’t do sln biopsy which has <1% regional control benefit . How great it must be to have your choosing wisely recs literally have no effect on patient outcome. Our choosing wisely should be don’t do regional nodal radiation for stage 1 luminal a breast cancer. That would be the equivalent

Our choosing wisely should be don't use proton therapy for stage 1 luminal breast cancer.

Data would argue this would save harm to some women and only hurt investors.

 

[Gfunk6]

Don't treat nodes for low or favorable intermediate risk prostate cancer

Here's a hot-take: Don't treat nodes in prostate cancer EVER unless they are proven to be positive by size criteria or if they are hot on PSMA PET. There has never been a proven overall survival advantage benefit of pelvic nodal radiation.

 

[OTN]

Here's a hot-take: Don't treat nodes in prostate cancer EVER unless they are proven to be positive by size criteria or if they are hot on PSMA PET. There has never been a proven overall survival advantage benefit of pelvic nodal radiation.

GETUG 18 fights against that a touch, but still would be nice to have true randomized data.

 

[Gfunk6]

GETUG 18 fights against that a touch, but still would be nice to have true randomized data.

Well, if you do the same thing in both arms you can't claim that intervention helped or not.

 

[OTN]

Well, if you do the same thing in both arms you can't claim that intervention helped or not.

Right, that's the issue. However, we can't deny the outcomes looked good to quite good.

 

[medgator]

Here's a hot-take: Don't treat nodes in prostate cancer EVER unless they are proven to be positive by size criteria or if they are hot on PSMA PET. There has never been a proven overall survival advantage benefit of pelvic nodal radiation.

Not everything we do in PCA has a goal of an OS benefit. Just look at prostate bed RT improving metastasis-free survival and decreasing future ADT need. Would definitely get my bed irradiated to decrease my chance of bone Mets or needing lifelong eligard in the future without any proven OS benefit

 

[evilbooyaa]

Here's a hot-take: Don't treat nodes in prostate cancer EVER unless they are proven to be positive by size criteria or if they are hot on PSMA PET. There has never been a proven overall survival advantage benefit of pelvic nodal radiation.

The more things change they more they stay the same.

I don't dictate how you practice, and I don't think its fair to dictate not covering nodes when POP-RT (forget 9413) showed DMFS advantage. Which is important.

 

[drowsy12]

Also I don’t know POP RT toxicity data off hand but 0534 showed very little additive grade 3 tox for treating pelvis

I could easily argue the other way, but to say never to treat the pelvis seems not totally accurate

 

[grenz]

Also I don’t know POP RT toxicity data off hand but 0534 showed very little additive grade 3 tox for treating pelvis

I could easily argue the other way, but to say never to treat the pelvis seems not totally accurate

POP RT showed 2x the rate of grade2+ late GU toxicity compared to prostate only. There’s definitely a downside.

 

[Gfunk6]

The more things change they more they stay the same.

I don't dictate how you practice, and I don't think its fair to dictate not covering nodes when POP-RT (forget 9413) showed DMFS advantage. Which is important.

Who is dictating? Just my opinion.

 

[RickyScott]

I thought there was a trial from India/Tara showing a benefit to nodal xrt in high risk?

 

[SneakyBooger]

Well, if you do the same thing in both arms you can't claim that intervention helped or not.

I think it shows photons are superior to protons.

 

[SneakyBooger]

POP-RT (forget 9413) showed DMFS advantage. Which is important.

DMFS was a post hoc analysis in POP-RT, which IMO negates the importance. I would view it as "hypothesis generating".

 

[evilbooyaa]

Who is dictating? Just my opinion.

Putting something into choosing wisely is 'dictating' in my opinion. I understand its your opinion that it should be put into and that's fine, but its my opinion that it specifically should not be because it takes away from patient autonomy (same as not recommend RT to 70yr old women w/ stage I breast cancer) in regards to what's important to the patient.

 

[TheWallnerus]

I mean, again, I have to mention how petty and destructive the ASTRO Choosing Wisely, existing from 2013 to 2022, against breast IMRT was.

Choosing Wisely came in with trumpets and fanfare if you all recall. It shuffled off this mortal coil with nary a mention of its demise. Oh, it's withdrawn? Hey. No biggie. No harm, no foul, amirite guys?

"ASTRO has withdrawn...", "Mistakes were made..."... don't you love the past exonerative tense?

"Thanks, ASTRO," in both instances of Wisely's birth and death.

 

[BobbyHeenan]

I mean, again, I have to mention how petty and destructive the ASTRO Choosing Wisely, existing from 2013 to 2022, against breast IMRT was.

Choosing Wisely came in with trumpets and fanfare if you all recall. It shuffled off this mortal coil with nary a mention of its demise. Oh, it's withdrawn? Hey. No biggie. No harm, no foul, amirite guys?

"ASTRO has withdrawn...", "Mistakes were made..."... don't you love the past exonerative tense?

"Thanks, ASTRO," in both instances of Wisely's birth and death.

View attachment 381961

Out of curiosity, I wonder if any other of the Choosing Wisely rec's from other specialties have been withdrawn?

This combined with the "registry trial" crap for prostate cancer (we all support RANDOMIZED trial...we are going to learn nothing from a registry trial in prostate...it's a trojan horse for insurance coverage) is a big time swing and miss...

 

[TheWallnerus]

Out of curiosity, I wonder if any other of the Choosing Wisely rec's from other specialties have been withdrawn?

This combined with the "registry trial" crap for prostate cancer (we all support RANDOMIZED trial...we are going to learn nothing from a registry trial in prostate...it's a trojan horse for insurance coverage) is a big time swing and miss...

Well actually yes. Afaik, this ABIM initiative has been sunsetted. For whatever reason.