What is a normal patient volume?

[RadRuss]

In general, IMRT should achieve more wRVUs than 3D, for lung. This is a bit outdated now, in terms of codes (and especially fractions), but the idea still stands:View attachment 379799View attachment 379800

Where might one locate tables like these for other sites? This is great

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Members don't see this ad.

 

[TheWallnerus]

Where might one locate tables like these for other sites? This is great

You would have to hack me!

 

[ramsesthenice]

Please use IMRT on all cases of locally advanced NSCLC.

If you're a cost shaming ivory tower research type, feel free to quote me in your future paper.

Ha! I still chuckle about this. When I was in training, some very well known people were convinced IMRT was going to kill lung cancer patients because the low dose bath would cause raging pneumonitis. So much for that.

Other “immoral” concepts which only existed for financial incentive included daily cone beam imaging, adaptive replanning, and brachytherapy boost for prostate cancer.

So glad it’s been > 10 years since I’ve had to listen to folks argue about “do we really need IMRT for that?”

 

[deleted1111261]

Ha! I still chuckle about this. When I was in training, some very well known people were convinced IMRT was going to kill lung cancer patients because the low dose bath would cause raging pneumonitis. So much for that.

Other “immoral” concepts which only existed for financial incentive included daily cone beam imaging, adaptive replanning, and brachytherapy boost for prostate cancer.

So glad it’s been > 10 years since I’ve had to listen to folks argue about “do we really need IMRT for that?”

Someone texted me the other day “when do you approve IMRT for X”

The answer is usually “always” for most curative indications.

It’s 2023. Litigating the battles of 2014

 

[NotMattSpraker]

Someone texted me the other day “when do you approve IMRT for X”

The answer is usually “always” for most curative indications.

It’s 2023. Litigating the battles of 2014

I like to think of each IMRT fraction for locally advanced lung as a small differential value that offsets the differential harm of each early stage breast proton fraction delivered in Florida.

These are the small selfless acts that make me a healthcare hero.

 

[OTN]

Someone texted me the other day “when do you approve IMRT for X”

The answer is usually “always” for most curative indications.

It’s 2023. Litigating the battles of 2014

Got denied IMRT for a T2N0 SCLC this past week

 

[medgator]

Someone texted me the other day “when do you approve IMRT for X”

The answer is usually “always” for most curative indications.

It’s 2023. Litigating the battles of 2014

Got denied IMRT for a T2N0 SCLC this past week

Unless N2 I've seen denials routinely for IMRT. Evilcore, United etc. Can usually come up with a decent 3D plan, but if paraspinal etc usually can appeal and get approval by showing a plan comparison.

 

[deleted1111261]

Got denied IMRT for a T2N0 SCLC this past week

Denied?? Very odd. Even protons are group 1 for lung. But, IMRT is not?

 

[metallica81788]

Denied?? Very odd. Even protons are group 1 for lung. But, IMRT is not?

It's something odd about United/Evicore and the particular SCLC diagnosis
They will push back for SCLC in the exact same scenario they wouldn't for NSCLC

Although I'm dealing with something insane at the moment - a lung SBRT that was approved, yet I changed fx from 5 to 10 (lesion was too big) and now it was denied and I'm on appeal #2. Probably the dumbest insurance related thing I've ever encountered.

 

[deleted1111261]

It's something odd about United/Evicore and the particular SCLC diagnosis
They will push back for SCLC in the exact same scenario they wouldn't for NSCLC

Although I'm dealing with something insane at the moment - a lung SBRT that was approved, yet I changed fx from 5 to 10 (lesion was too big) and now it was denied and I'm on appeal #2. Probably the dumbest insurance related thing I've ever encountered.

So, not that you did anything wrong, but this happens from time to time and there isn't an adjustment from SBRT to IMRT. And then it all gets confused. I get that it should be obvious that if you are now doing 10 instead of 5, it is no longer SBRT, but the mismatch on the request can cause issues. This is so frustrating.

 

[evilbooyaa]

Got denied IMRT for a T2N0 SCLC this past week

I've had to show 3D vs IMRT comparison plans for any non-N2 locally advanced NSCLC, even T3N0 or T2N1 pts getting definitive chemoRT.

Stupid, IMO. But you can treat a T2N0 that's not paraspinal with 3D with 'acceptable' V20s.... Evicore doesn't care if it's way lower w/ IMRT, even in a sick patient (hence why they were getting chemoRT)

 

[IonsAreOurFuture]

Ha! I still chuckle about this. When I was in training, some very well known people were convinced IMRT was going to kill lung cancer patients because the low dose bath would cause raging pneumonitis. So much for that.

Other “immoral” concepts which only existed for financial incentive included daily cone beam imaging, adaptive replanning, and brachytherapy boost for prostate cancer.

So glad it’s been > 10 years since I’ve had to listen to folks argue about “do we really need IMRT for that?”

I remember when one of my physicists told me that IMRT would never work for lung cancer, because the tumor moves, and the MLCs move, so you're going to underdose a lot of the tumor.

It didn't work out that way, so I guess after 30 fractions it's all a wash. Maybe today's slightly underdosed area is tomorrow's hotspot.


I too remember getting a lot of insurance pushback for using IMRT for indications that used to be 3D conformal 15 years ago, and I find the same tired arguments being applied to proton therapy now.

 

[evilbooyaa]

I remember when one of my physicists told me that IMRT would never work for lung cancer, because the tumor moves, and the MLCs move, so you're going to underdose a lot of the tumor.

It didn't work out that way, so I guess after 30 fractions it's all a wash. Maybe today's slightly underdosed area is tomorrow's hotspot.


I too remember getting a lot of insurance pushback for using IMRT for indications that used to be 3D conformal 15 years ago, and I find the same tired arguments being applied to proton therapy now.

Pray tell what diagnoses you think proton therapy should be considered a SoC option in terms of radiation, currently?

 

[IonsAreOurFuture]

Pray tell what diagnoses you think proton therapy should be considered a SoC option in terms of radiation, currently?

The 2023 ASTRO coverage guideline is a pretty decent place to start and would cover about 20% of what most depts see.

The most common indication I treat with protons is not organ specific, per se, but rather is OAR and patient-specific, ie when unable to meet published constraints such as QUANTEC with IMRT but able to meet with protons.

 

[Chartreuse Wombat]

The 2023 ASTRO coverage guideline is a pretty decent place to start and would cover about 20% of what most depts see.

The most common indication I treat with protons is not organ specific, per se, but rather is OAR and patient-specific, ie when unable to meet published constraints such as QUANTEC with IMRT but able to meet with protons.

20% ok. Tell us about the 80%. Early stage breast, prostate?

 

[TheWallnerus]

The most common indication I treat with protons is not organ specific, per se, but rather is OAR and patient-specific,

Not pointing any fingers your way per se. But every single insurance company appeal letter from a proton center says protons cause less second cancers versus photons. Taking this to its logical conclusion… wouldn’t protons be SOC for everything photons are.

 

[IonsAreOurFuture]

20% ok. Tell us about the 80%. Early stage breast, prostate?

You are correct, a lot of places are treating whomever walks in the door, but this also happens in Xray centers. For those in proton only facilities, they have no other in-house option, and vice-versa for Xray centers, so I try not to judge too harshly. We are all doing the best we can with what we have. I am really fortunate to have both options for my patients, who are the ultimate beneficiaries of what we do.

I do use protons for early stage breast cancer, typically for patients who meet the 2023 ASTRO guideline, e.g. under age 40 (2nd malignancy risk) and/or left-sided breast CA if I'm unable to meet heart constraints despite using DIBH, prone, or a heart block. On a clinical trial is another indication for early stage breast CA.

Heart constraints have gotten a lot stricter lately after the paper by Zureick, et al, in the Red Journal. Cardiac mean dose on the order of 1 Gy and LAD mean dose of 3 Gy are not easy to meet, but predict for major adverse Cardiac events at 4 years post tx. This was a bit of a surprise to me, as I thought those changes would take decades to show up.

I have used protons for early stage prostate on COMPPARE trial, but only rarely off protocol. I usually tell patients that there isn't much difference between a good IMRT plan for prostate-only dz and an average proton plan. Especially with a good SPACEOAR, but I know that is a controversial topic here.

I do see a big improvement in bowel and bladder midline sparing for prostate when treating pelvic nodes with IMPT as compared to IMRT. Treating involved pelvic and para-aortic nodes is part of the ASTRO 2023 recommendactions, which makes sense to me because usually I'm trying to give 70+ Gy to gross dz but the bowel tolerance is closer to 50.

I have treated a couple patients with ulcerative colitis who were medically inoperable using protons, due to the better bowel sparing, but still felt pretty nervous about it. There's lot of scenarios where we simply don't know until we make the comparison plans.

 

[IonsAreOurFuture]

Not pointing any fingers your way per se. But every single insurance company appeal letter from a proton center says protons cause less second cancers versus photons. Taking this to its logical conclusion… wouldn’t protons be SOC for everything photons are.

If patients have a 20+ year life expectancy, I do make mention of it. Usually approvals are due to immediate toxicity constraints with hard data on organ limits. Safety in the short run is typically what it boils down to, except for under 40 year olds.

 

[deleted1111261]

The hardest part for me is that they’ve had decades to write studies. And so few have been attempted, fewer published. I’ve had a discussion with just one physician who immediately agreed to put patient on study when I said they would get approved that way. I shouldn’t have to ask - come to me with them enrolled - this is what Medicare and Astro want for group 2.

And the pressure I get from ordering physicians is “it’s just better, look at the DVH, are you stupid?” And without getting into theoretical benefits and a discussion of statistics, there is just an angry person on the other end trying to ask for protons on a stage breast cancer.

Almost always, prone plans will be beautiful. Partial breast is almost always an option and that isn’t attempted. And for certain constraints - both the photon and proton plan will be well below, but “the proton one is better”. For prostate, the majority of the clinical data just isn’t better.

With modern RT, the probability of a second malignancy is exceedingly low.

And when I say any of this, they still rail against me rather than addressing any of the points.

 

[OTN]

The hardest part for me is that they’ve had decades to write studies. And so few have been attempted, fewer published. I’ve had a discussion with just one physician who immediately agreed to put patient on study when I said they would get approved that way. I shouldn’t have to ask - come to me with them enrolled - this is what Medicare and Astro want for group 2.

And the pressure I get from ordering physicians is “it’s just better, look at the DVH, are you stupid?” And without getting into theoretical benefits and a discussion of statistics, there is just an angry person on the other end trying to ask for protons on a stage breast cancer.

Almost always, prone plans will be beautiful. Partial breast is almost always an option and that isn’t attempted. And for certain constraints - both the photon and proton plan will be well below, but “the proton one is better”. For prostate, the majority of the clinical data just isn’t better.

With modern RT, the probability of a second malignancy is exceedingly low.

And when I say any of this, they still rail against me rather than addressing any of the points.

"It's just better, look at the DVH" includes the underlying presupposition that we know exactly what protons are doing and what the RBE is in both the short- and long-term. Due to the paucity of the type of data you mentioned, this is not clear.

 

[deleted1111261]

The reality is, the younger docs seem to understand proton physics/biology and indications a lot better than the older ones, and are much more likely to be taking the call to appease a boss or patient, rather than going psycho on you for something silly. I presume the proton training during residency / fellowship is better than people that got a machine a few years ago after routinely treating with photons/electrons for the last 2-3 decades.

 

[Neuronix]

The younger docs have no financial investment. We're here getting the same salary no matter what happens. Even if there's some tie to wRVUs or professional collections, we're not making more for protons which is all on the technical side.

The chairs and practice partners need patients on beam for their own finances and careers.

 

[Bequerel]

The hardest part for me is that they’ve had decades to write studies. And so few have been attempted, fewer published. I’ve had a discussion with just one physician who immediately agreed to put patient on study when I said they would get approved that way. I shouldn’t have to ask - come to me with them enrolled - this is what Medicare and Astro want for group 2.

And the pressure I get from ordering physicians is “it’s just better, look at the DVH, are you stupid?” And without getting into theoretical benefits and a discussion of statistics, there is just an angry person on the other end trying to ask for protons on a stage breast cancer.

Almost always, prone plans will be beautiful. Partial breast is almost always an option and that isn’t attempted. And for certain constraints - both the photon and proton plan will be well below, but “the proton one is better”. For prostate, the majority of the clinical data just isn’t better.

With modern RT, the probability of a second malignancy is exceedingly low.

And when I say any of this, they still rail against me rather than addressing any of the points.

Seems like you have a good clinical gig with decent pay and hours. Why bother with peer review? Sounds like it could be miserable at times

 

[deleted1111261]

Seems like you have a good clinical gig with decent pay and hours. Why bother with peer review? Sounds like it could be miserable at times

I push back here when I feel people unfairly characterizing it. I really enjoy reviewing cases and working on guidelines. I want streamlining for physicians and patients not to be mad. I’ve been complimented several times for how I approach the cases by the docs. I get a few bad apples occasionally, it stresses me out, but I do understand most want what’s best for their patient.

And, we are finishing the basement. This helps!

 

[fiji128]

I do use protons for early stage breast cancer, typically for patients who meet the 2023 ASTRO guideline, e.g. under age 40 (2nd malignancy risk) and/or left-sided breast CA if I'm unable to meet heart constraints despite using DIBH, prone, or a heart block. On a clinical trial is another indication for early stage breast CA.

Heart constraints have gotten a lot stricter lately after the paper by Zureick, et al, in the Red Journal. Cardiac mean dose on the order of 1 Gy and LAD mean dose of 3 Gy are not easy to meet, but predict for major adverse Cardiac events at 4 years post tx. This was a bit of a surprise to me, as I thought those changes would take decades to show up.

Just wait until you see the mean heart dose you can get with zero Gy for those early stage breast!

 

[RickyScott]

Seems like you have a good clinical gig with decent pay and hours. Why bother with peer review? Sounds like it could be miserable at times

depends on the time spent on um. 5-10 hours a week is incredibly enlightening and with 15 pts on beam, only have a 4-5 hour work day.
I did um for a few hours a week a number of years ago and came away thoroughly disgusted with the state of academic radonc. Everyone should do it.

 

[Tigerstang]

Seems like you have a good clinical gig with decent pay and hours. Why bother with peer review? Sounds like it could be miserable at times

Because radiation oncologists are greedy, and willing to sell their license and violate the hippocratic oath (first DO NO HARM) for a buck.

 

[TheWallnerus]

Because radiation oncologists are greedy, and willing to sell their license and violate the hippocratic oath (first DO NO HARM) for a buck.

You could always take a kind of Galen Erso approach to UM.

 

[deleted1111261]

Because radiation oncologists are greedy, and willing to sell their license and violate the hippocratic oath (first DO NO HARM) for a buck.

What about radiation oncologists in Florida doing things like BID 60 Gy in 60 Fx for curable breast cancer? Or similar for lung, rectal and head neck?

Let's re-phrase your inflammatory comment - "Because some radiation oncologists from certain regions of the country are greedy, other radiation oncologists have to deal with prior authorization and those that work on the PA end take a very low salary to help "educate" physicians."

You can insult me if you want, but I know I'm not the problem. My position would not exist if it weren't for the scoundrels.

Please keep on keeping on tho, the non-EBM wildness is what keeps me employed. I really do enjoy the work; would be sad if everyone practiced standard of care and I got canned.

 

[Ray D. Ayshun]

What about radiation oncologists in Florida doing things like BID 60 Gy in 60 Fx for curable breast cancer? Or similar for lung, rectal and head neck?

Let's re-phrase your inflammatory comment - "Because some radiation oncologists from certain regions of the country are greedy, other radiation oncologists have to deal with prior authorization and those that work on the PA end take a very low salary to help "educate" physicians."

You can insult me if you want, but I know I'm not the problem. My position would not exist if it weren't for the scoundrels.

Please keep on keeping on tho, the non-EBM wildness is what keeps me employed. I really do enjoy the work; would be sad if everyone practiced standard of care and I got canned.

There is no protonist in any good story without an anionist.

 

[Neuronix]

Yeah how about Gamma Knife x2 11 Gy each to CNS NGGCT involving brainstem? I can only wish that got peer reviewed before landing in my lap.

 

[Mandelin Rain]

Yeah how about Gamma Knife x2 11 Gy each to CNS NGGCT involving brainstem? I can only wish that got peer reviewed before landing in my lap.

How bad was it?

 

[communitydoc13]

Yeah how about Gamma Knife x2 11 Gy each to CNS NGGCT involving brainstem? I can only wish that got peer reviewed before landing in my lap.

I'm confused. What was the rationale?

 

[theradiator]

I'm confused. What was the rationale?

That is staged SRS promulgated by Cleveland Clinic and Timmerman has invoked staged SRS as a rationale for PULSAR. Not crazy but probably not standard of care yet either.

 

[Reaganite]

Because radiation oncologists are greedy, and willing to sell their license and violate the hippocratic oath (first DO NO HARM) for a buck.

Do some UM work, and you'll change your tune.

What about radiation oncologists in Florida doing things like BID 60 Gy in 60 Fx for curable breast cancer? Or similar for lung, rectal and head neck?

Let's re-phrase your inflammatory comment - "Because some radiation oncologists from certain regions of the country are greedy, other radiation oncologists have to deal with prior authorization and those that work on the PA end take a very low salary to help "educate" physicians."

You can insult me if you want, but I know I'm not the problem. My position would not exist if it weren't for the scoundrels.

Please keep on keeping on tho, the non-EBM wildness is what keeps me employed. I really do enjoy the work; would be sad if everyone practiced standard of care and I got canned.

Did reviews myself many years ago more to learn how to game the system, but in the process I learned there are a TON of bad apples out there requesting absolutely ridiculous things. It was very eye opening. As Simul stated, these jobs wouldn't exist without an abundance of scoundrels.

 

[medgator]

Do some UM work, and you'll change your tune.

Did reviews myself many years ago more to learn how to game the system, but in the process I learned there are a TON of bad apples out there requesting absolutely ridiculous things. It was very eye opening. As Simul stated, these jobs wouldn't exist without an abundance of scoundrels.

Would have been solved long ago if the field (cough*ASTRO*cough) had embraced site-neutral payment bundles. Easiest way to watch AIM, evilcore and the like go out of business

 

[evilbooyaa]

"It's just better, look at the DVH" includes the underlying presupposition that we know exactly what protons are doing and what the RBE is in both the short- and long-term. Due to the paucity of the type of data you mentioned, this is not clear.

We actually have a decent amount of data that suggests due to RBE variations that are at the whim of a multitude of factors that we have, not only at CT sim but also during day to day variation, it is quite clear that some proportion of what a proton plan show on the computer are explicitly NOT what the patient is getting, resulting in overdosing of up to 50%.

The fact anyone feels comfortable with this fact and continues to treat with protons routinely is befuddling to me.

 

[communitydoc13]

That is staged SRS promulgated by Cleveland Clinic and Timmerman has invoked staged SRS as a rationale for PULSAR. Not crazy but probably not standard of care yet either.

Oh...thanks for the info.

My instinct would be to be conservative here (3-5 fractions).

Wonder what the outcome was?

I'm just community, so I don't see NGGCT. Used to be a whole brain disease, but I gather there is comfort with omitting WBRT at this point?

 

[Neuronix]

I'm confused. What was the rationale?

That is staged SRS promulgated by Cleveland Clinic and Timmerman has invoked staged SRS as a rationale for PULSAR. Not crazy but probably not standard of care yet either.

This is not metastatic, and the staged SRS/PULSAR data does not apply for primary CNS NGGCT to the best of my knowledge.

I have no explanation.

 

[communitydoc13]

This is not metastatic

Wow...my only guess is someone thought it was metastatic.

 

[A_DeMichele]

here is Part 2 of Propublica’s attack on UM… pretty sad read for everyone. RadOnc is mentioned with the denial of protons for NP cancer for 1 case.

Doctors With Histories of Big Malpractice Settlements Work for Insurers, Deciding If They’ll Pay for Care

Doctors working for health insurers can rule on 10,000 or more requests for care a year. At least a dozen were hired by major insurance companies after being disciplined by state medical boards or making multiple or outsized malpractice payments.

www.propublica.org

 

[deleted1111261]

here is Part 2 of Propublica’s attack on UM… pretty sad read for everyone. RadOnc is mentioned with the denial of protons for NP cancer for 1 case.

Doctors With Histories of Big Malpractice Settlements Work for Insurers, Deciding If They’ll Pay for Care

Doctors working for health insurers can rule on 10,000 or more requests for care a year. At least a dozen were hired by major insurance companies after being disciplined by state medical boards or making multiple or outsized malpractice payments.

www.propublica.org

Brutal article. Net, mostly true.

So, for us, none of us have malpractice claims and the RadOncs have to work full time.

A nurse or algorithm cannot deny a case.

I review any case that is up for denial.

We use national guidelines and they supervise any of my own judgments (protons for dcis if on registry).

But, this article exposes a lot of flaws at other companies.

 

[IonsAreOurFuture]

here is Part 2 of Propublica’s attack on UM… pretty sad read for everyone. RadOnc is mentioned with the denial of protons for NP cancer for 1 case.

Doctors With Histories of Big Malpractice Settlements Work for Insurers, Deciding If They’ll Pay for Care

Doctors working for health insurers can rule on 10,000 or more requests for care a year. At least a dozen were hired by major insurance companies after being disciplined by state medical boards or making multiple or outsized malpractice payments.

www.propublica.org

I know this is a complex issue, but I sympathize with the MD Anderson rad onc and the patient who got denied proton therapy by non-specialists. I've been there.

I had a case just this year where the insurance company representative kept saying "protein therapy" instead of proton therapy. At first I thought it was a simple mistake so I started keeping count and got to about 8 times before I pointed it out to her. She clearly didn't know what she was talking about. (I've yet to have a peer call with someone who actually uses proton therapy)

Even so, "protein" therapy was denied, and the patient and I were powerless to reverse it.


I think Simul is one of the good ones, and I know he keeps up with our field. His company sounds more ethical than most, but there are also a lot of bad apples out there.

 

[Bequerel]

I know this is a complex issue, but I sympathize with the MD Anderson rad onc and the patient who got denied proton therapy by non-specialists. I've been there.

I had a case just this year where the insurance company representative kept saying "protein therapy" instead of proton therapy. At first I thought it was a simple mistake so I started keeping count and got to about 8 times before I pointed it out to her. She clearly didn't know what she was talking about. (I've yet to have a peer call with someone who actually uses proton therapy)

Even so, "protein" therapy was denied, and the patient and I were powerless to reverse it.

I was thinking the opposite. Why wait months and let a family mortgage a house for protons when it’s obviously not going to get approved? We treated nasopharyngeal cancer successfully for years without it.

 

[drowsy12]

I was thinking the opposite. Why wait months and let a family mortgage a house for protons when it’s obviously not going to get approved? We treated nasopharyngeal cancer successfully for years without it.

yep. you definitely do not need proton for NPC, and in some cases will be worse than photon at tight gradient plans near brainstem, optics.

in before someone comes in talking abbot 'low dose bath' to the lens. come on.

 

[communitydoc13]

Brutal article.

The article is crappy.

Several points.

They focus on the malpractice history of some medical directors without assessing how significantly different this workforce is from practicing physicians of similar age, gender (yes it is correlated strongly with malpractice history) and specialty. They perhaps intentionally use misleading statistics to imply that medical directors represent crazy outliers as a group (I'm sure there are some.)

There is a 31% chance of being sued during one's career with a marked increase in likelihood of suit with each preceding instance. There are lots of general surgeons who are fine that have been sued twice. It is also true that a pattern of claims is concerning and that at some point, many of these docs are driven from clinical practice. (The three worst docs that I have worked with in the community are still practicing somewhere). Older docs are of course more likely to have been sued than younger docs.

MDACC come off as schmucks in both or these articles, although clearly the intent is to present them as paragons of best practice in radiation oncology (I'm a bit suspicious). MDACC should never be making patients wait months for protons (with the possible exception of indolent disease that will truly benefit from protons...I can't personally think of a scenario myself). These cases represent institutional greed and inflexibility, not villainy by UM.

I'm no fan of our present system or the way that UM typically functions. However, I have actually had better experiences over the past couple years for whatever reason (maybe an adjustment in my approach). There are scenarios where I will order things that are not in NCCN guidelines (e.g. PET imaging in some GYN or rectal cases) but have been able to convince reviewing docs of value (I believe PET provides value to the treating radonc in the setting of equivocal adenopathy outside of the mesorectum and a times for assisting in delineation of distal extent of disease at diagnosis).

 

[deleted1111261]

The main issue with PA failure is the lack of communication. I’m on the clock and I feel it. I don’t let cases sit. They are required to make at least 3 attempts to contact you. You can request a P2P. A non MD should never not be your peer. I’ve rarely encountered a non RO, but if that happens, escalate. Ask to talk to the CMO. Mention the payor’s star rating. Expedite as much as you can on these cases. For these denials without P2P, make sure you have all the documents company has sent. It had better be 3 attempts.

In cases of delays, we have to get over this idea that we can’t do what we want. We can. We just may not get paid for it. Treat patient, retro it, appeal the lower cost treatment and prove you delivered it.

Start filing complaints. Cc the state/local politicians. Blast them on social media.

When they are inappropriate, that’s a declaration of war. Cannot just take it. Don’t get nasty / mad. But slowly continue to build your case of their negligence.

The payors need to know how bad Evicore is. I talked to the CMO of a massive payor, and they said they know that Evicore is awful. But contracts are hard to unwind. Keep the pressure up.

 

[radiaterMike]

(protons for dcis if on registry)

Those registries that enroll any patient with any disease should not be a 'golden ticket' for proton approval. Protons for 4 Gy x 5 palliation of a femur met on registry ? I understand that the ASTRO Model Policy seems to allow for this ("All other indications not listed in Group 1 are suitable for Coverage with Evidence Development (CED). Radiation therapy for patients treated under the CED paradigm should be covered by the insurance carrier as long as the patient is enrolled in either an IRB-approved clinical trial or in a multi-institutional patient registry adhering to Medicare requirements for CED2" but I would not consider this policy a consensus guideline or something that insurers need to strictly adhere to - particularly when common sense does not prevail. Private insurers are not going to jump a the opportunity to put patients on a registry and do not necessarily have to do that.

 

[deleted1111261]

Those registries that enroll any patient with any disease should not be a 'golden ticket' for proton approval. Protons for 4 Gy x 5 palliation of a femur met on registry ? I understand that the ASTRO Model Policy seems to allow for this ("All other indications not listed in Group 1 are suitable for Coverage with Evidence Development (CED). Radiation therapy for patients treated under the CED paradigm should be covered by the insurance carrier as long as the patient is enrolled in either an IRB-approved clinical trial or in a multi-institutional patient registry adhering to Medicare requirements for CED2" but I would not consider this policy a consensus guideline or something that insurers need to strictly adhere to - particularly when common sense does not prevail. Private insurers are not going to jump a the opportunity to put patients on a registry and do not necessarily have to do that.

I agree, but the contractors likely will not and the ALJs are not competent about health care (judges say protein beam often). It’s a fair point that it’s not common sense, but my lead says with that wording that we should tread lightly. The CED2 requirements are fairly stringent. I think will revisit and try to talk to someone about this further.

 

[radiaterMike]

From what I understand, Dr Spratt is a strong advocate of the protein beam.