A new low for insurance coverage

[ramsesthenice]

We all deal with denials for IMRT, IGRT, SBRT, etc. I have a patient with an extensive GEJ tumor that was denied coverage for 4DCT or VMAT (so I had to bill everything per plan). This morning I got this beauty in my inbox regarding the same patient:

"Please draft a letter of necessity for 3DCRT for ************* "

Necessity for 3DCRT? Is someone seriously implying we should think about using 2D planning for a definitive GEJ case (or any definitive case for that matter)? This feels like a new low to me and an epic waste of time and resources.

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[radiaterMike]

I'm just curious- did you draft a 3D vs. VMAT plan for the patient ? There is a process to appeals, but usually if you have a plan comparison showing a clinically meaningful benefit of IMRT (not just dose reduction to normal tissues - but one of that shows that QUANTEC, NCCN or RTOG protocol constraints cannot be met) it will be approved. Sometimes it needs to go to independent review if your state allows for that. It is frustrating that you essentially are asking your dosimetrist to generate 2 plans, which is not reimbursed extra time. And it sounds like you may have to do that anyway to get 3D covered. I have no sympathy for insurers, but this extra work stems from the abuses of IMRT (i.e. 3 Gy x 10 to a lateral rib met).

 

[Krukenberg]

I'm just curious- did you draft a 3D vs. VMAT plan for the patient ? There is a process to appeals, but usually if you have a plan comparison showing a clinically meaningful benefit of IMRT (not just dose reduction to normal tissues - but one of that shows that QUANTEC, NCCN or RTOG protocol constraints cannot be met) it will be approved. Sometimes it needs to go to independent review if your state allows for that. It is frustrating that you essentially are asking your dosimetrist to generate 2 plans, which is not reimbursed extra time. And it sounds like you may have to do that anyway to get 3D covered. I have no sympathy for insurers, but this extra work stems from the abuses of IMRT (i.e. 3 Gy x 10 to a lateral rib met).

I hate the increasing burden of P2Ps, but I agree it all stems from physicians over utilizing imaging and more expensive treatments. That applies to academics and PP alike

 

[ramsesthenice]

I have no sympathy for insurers, but this extra work stems from the abuses of IMRT (i.e. 3 Gy x 10 to a lateral rib met).

I agree with you on why they do this and I am generally ok with reviewing things on a case-by-case basis. But I have never had to defend doing 3D for a definitive plan. That is getting a bit extreme and frankly becoming as much of a waste of resources and cost as over zealous use of technology by physicians.

As to your first question, no I did not make a 3D plan because this particular insurer simply does not cover IMRT or VMAT for esophageal tumors. Period. No matter what you show them on the DVH so I didn't even bother (though I would other carriers and I usually make my residents generate 3D and IMRT plans for esophageal tumors so that they know how to do both). I still use 3D from time to time for appropriate esophageal tumors but this thing was huge and the benefits of VMAT were probably clinically meaningful so I used it thinking it was in the guys best interest.

 

[RadOncDoc21]

I wouldn't be so quick to argue for the insurance companies. Yes, there are docs that do increase the cost of health care, the insurance company only goal is to make a profit and not provide the best health care services available.

 

[radiaterMike]

ramsesthenice - you can check if your state has independent review, in which case the denial may be overturned (as standard medical necessity criteria might apply, as opposed to the insurer's policy)

RadOncDoc - yes, they are for profit, which creates a huge conflict of interest.

 

[deleted18755]

We all deal with denials for IMRT, IGRT, SBRT, etc. I have a patient with an extensive GEJ tumor that was denied coverage for 4DCT or VMAT (so I had to bill everything per plan). This morning I got this beauty in my inbox regarding the same patient:

"Please draft a letter of necessity for 3DCRT for ************* "

Necessity for 3DCRT? Is someone seriously implying we should think about using 2D planning for a definitive GEJ case (or any definitive case for that matter)? This feels like a new low to me and an epic waste of time and resources.

This has to be an error...

 

[evilbooyaa]

Agree that it has to be in error. I've never seen somebody have to justify the use of a CT scan.

If it's for real, I think you should go public with it, with an insurance company telling you that you have to treat somebody with techniques that are not only 10+ years old, but 25-30 years old!

 

[radiaterMike]

I think the rationale for 2D is that the stomach moves, and that it could easily be encompassed in a giant 2D field. In reality, that is poor rationale, since your PTV would account for motion (and you can be as generous as you think you need to be), IGRT could be used, and even if you use the Evicore definition of 3D requiring DVHs for 3+ OARs, this case would qualify since you will look at bowel, kidneys, cord ...

 

[RickyScott]

Most likely an error. A lot has to do with the clerical staff submitting the case or receiving it at the insurance company, and the subsequent autoprompts. I have had a few instances like this occur that ended up peer to peer because some new lowly paid staff filled out incorrect info, like checking some box that the patient had metastatic disease.

BTW: If you truly think insurance companies are raking in so much money, you should buy stock in them and look at PE ratios.

 

[RadOncDoc21]

Most likely an error. A lot has to do with the clerical staff submitting the case or receiving it at the insurance company, and the subsequent autoprompts. I have had a few instances like this occur that ended up peer to peer because some new lowly paid staff filled out incorrect info, like checking some box that the patient had metastatic disease.

BTW: If you truly think insurance companies are raking in so much money, you should buy stock in them and look at PE ratios.

Hence why they may feel more pressure to decline claims.

 

[Mandelin Rain]

Health insurer profits are measured in billions, with a "b."

When a patient is sitting across from me, I care more about their health than the dividend paid to investors. I don't get the impression that United Health Care feels the same way. Any insurer crying poor will get no sympathy from me when they are wasting my time with nonsensical and nonpaid work.

 

[medgator]

There is a reason why the tide is turning towards single payer...both in the population at large and the medical community....

New Poll Finds Majority of GOP Voters Support Medicare for All

Doctors Used to Be the Greatest Opponents of Universal Health Care. Now They’re Embracing It

Many of us are dealing with non medical staff and nurse reviewers trying to practice medicine at evicore and med solutions, so at this point, the boogeyman of govt control isn't really going to share us, but certainly some of that profit can go back into the system rather than CEO payouts and dividends

 

[RickyScott]

Health insurer profits are measured in billions, with a "b."

When a patient is sitting across from me, I care more about their health than the dividend paid to investors. I don't get the impression that United Health Care feels the same way. Any insurer crying poor will get no sympathy from me when they are wasting my time with nonsensical and nonpaid work.

I dont sympathize with insurance companies, but they are not the primary driver of spiraling health care costs, which is what is prompting these reviews.
Regarding a single payer system, I am under the impression that most health care economists see that as inevitable because present trends are not sustainable. In such a system your regional hospital/health monopolies will no longer have their extortion/power advantage.

 

[OTN]

There is a reason why the tide is turning towards single payer...both in the population at large and the medical community....

New Poll Finds Majority of GOP Voters Support Medicare for All

Doctors Used to Be the Greatest Opponents of Universal Health Care. Now They’re Embracing It

Many of us are dealing with non medical staff and nurse reviewers trying to practice medicine at evicore and med solutions, so at this point, the boogeyman of govt control isn't really going to share us, but certainly some of that profit can go back into the system rather than CEO payouts and dividends

The tide is turning because people are being told lies about what M4A would be. The very first line- the very first! in that second link you list says "There's a generational shift happening, where we see universal health care as a requirement," one physician says. They waste no time off the bat conflating universal health care with M4A, which of course are nothing like one another.

While, true, people do like M4A when they're asked about it, when they're told the details of the plan (outlawing of private insurance companies, more than doubling of federal and corporate income taxes, etc), 80+% of all Americans no longer support it.

I cannot understand why anyone in the medical field who cares about patients or providers would support the creation of a legal monopsony designed to push the price paid for medical care below what the market would ordinarily bear, leading to inefficiencies and complete halting of innovation. Why not have universal care but still have multiple payers in the market? Why outlaw private payers? What possible good does that do? What if fiscal conservatives gain control of the government? Won't they use their power to starve the system of resources, as is exactly happening in the NHS?

Healthcare is NOT a public good- it is both consumable AND excludable, meaning there is no reason for the government to take over its financing. Again, I agree with universal care/coverage, but M4A would be a disaster for both patients and providers.

 

[BobbyHeenan]

I've never had an issue with VMAT for esophagus. Rarely I will need a 3-D comparison, but with that I can't ever recall a denial.

Isn't it nuts that some providers will approve off protocol protons for esophagus while others will only pay for 3D?

 

[evilbooyaa]

Yeah I think having a blanket statement like "No IMRT for Esophagus ever" as a blanket denial is a huge issue as IMO, IMRT is standard of care (similar to lung) for preoperative/definitive Esophagus/GEJ.

 

[medgator]

The tide is turning because people are being told lies about what M4A would be. The very first line- the very first! in that second link you list says "There's a generational shift happening, where we see universal health care as a requirement," one physician says. They waste no time off the bat conflating universal health care with M4A, which of course are nothing like one another.

While, true, people do like M4A when they're asked about it, when they're told the details of the plan (outlawing of private insurance companies, more than doubling of federal and corporate income taxes, etc), 80+% of all Americans no longer support it.

I cannot understand why anyone in the medical field who cares about patients or providers would support the creation of a legal monopsony designed to push the price paid for medical care below what the market would ordinarily bear, leading to inefficiencies and complete halting of innovation. Why not have universal care but still have multiple payers in the market? Why outlaw private payers? What possible good does that do? What if fiscal conservatives gain control of the government? Won't they use their power to starve the system of resources, as is exactly happening in the NHS?

Healthcare is NOT a public good- it is both consumable AND excludable, meaning there is no reason for the government to take over its financing. Again, I agree with universal care/coverage, but M4A would be a disaster for both patients and providers.

It's a tricky issue, but many of the things that people rail about against single payer are happening now in the current system with insurance company denials.

Doctors aren't being allowed to make their best medical decision, to the detriment of patients and benefit of the for profit insurance industry (vs the govt in single payer).

 

[OTN]

It's a tricky issue, but many of the things that people rail about against single payer are happening now in the current system with insurance company denials.

Doctors aren't being allowed to make their best medical decision, to the detriment of patients and benefit of the for profit insurance industry (vs the govt in single payer).

True, which is why I'm not completely against case-based reimbursement. Let us decide what we want to do for the patient's sake and give us a chunk of money to do it. Make that chunk of money the same between free-standing and hospital-based practices and now we're talking.

 

[seper]

Back to original topic, I wholeheartedly agree with 4D CT for GEJ tumors. Some respiratory movements I've seen are really extreme in this part of the body.
However, IMRT here is not a slam dunk. It spares heart better than 3D but is it worth the risk of underdosing the target? Only 30% of patients of so survive long enough to be at risk of radiation-induced heart disease.

 

[evilbooyaa]

Why would IMRT underdose the target? Dose coverage with IMRT is nearly always better than with 3D

 

[radiaterMike]

Relative to standard 3D, IMRT would be more likely to underdose the target if the PTV margins are insufficient to account for organ motion and/or IGRT is not used (or not used well - i.e. aligning to spine). A 10 cm PTV expansion wont underdose the target whereas a 1 mm expansion would. The right expansion is somewhere in between those 2 crazy extremes.

 

[scarbrtj]

IMRT would be more likely to underdose the target if the PTV margins are insufficient

I resisted commenting but IMRT will in and of itself never underdose a target. Never. A human (rad onc) can, via inadequate PTV coverage. Everything that can or can't happen re: 3DCRT can happen w/ IMRT and vice versa (inadequate PTVs "hurt" 3DCRT too). Even when we factor in moving targets, if the PTV encompasses the motion (ITV), over multiple fractions this evens out... moving targets (moving target voxels more specifically) are as likely to "see" overdose as underdose when fluences are inhomogenous. Also, alignment to any particular nearby "anatomic fiducial" (ie aligning to spine in an esophageal case) is not guaranteed infaust, will vary in effectiveness from patient to patient (may be a good alignment in some cases), and again will be dependent on PTV margin choice (so that the CTV+/-GTV will be correctly dosed).

 

[nkmiami]

I resisted commenting but IMRT will in and of itself never underdose a target. Never. A human (rad onc) can, via inadequate PTV coverage. Everything that can or can't happen re: 3DCRT can happen w/ IMRT and vice versa. Even when we factor in moving targets, if the PTV encompasses the motion (ITV), over multiple fractions this evens out... moving targets (moving target voxels more specifically) are as likely to "see" overdose as underdose when fluences are inhomogenous. Also, alignment to any particular nearby "anatomic fiducial" (ie aligning to spine in an esophageal case) is not guaranteed infaust, will vary in effectiveness from patient to patient (may be a good alignment in some cases), and again will be dependent on PTV margin choice (so that the CTV+/-GTV will be correctly dosed).

beat me to it

 

[ramsesthenice]

This has to be an error...

Sadly, its not. Like I said, they have already denied me coverage for IMRT and 4DCT for this particular patient. They have now sent a separate request asking for justification for 3DCRT. It sounds like you are having as much trouble as I am believing this. I had to read it a couple times to make sure I was seeing it right.

I think the discussion about IMRT vs 3DCRT for GEJ tumors is an interesting one. I actually tend to agree with Seper. IMRT is not always a slam dunk. I wanted it for this case largely because he has some fairly chunky celiac nodes that don't move much and are pretty close to bowel. Dose shaping with IMRT for this particular case made a difference around the involved nodes. However, the primary GTV and GEJ move a lot and by the time I made an ITV and PTV the fields were huge and not that much different from what they would have been with a good 3D plan. For distal tumors the advantage of IMRT is not always great.

 

[radiaterMike]

I think we are saying the same things.

I resisted commenting but IMRT will in and of itself never underdose a target. Never. A human (rad onc) can, via inadequate PTV coverage. Everything that can or can't happen re: 3DCRT can happen w/ IMRT and vice versa (inadequate PTVs "hurt" 3DCRT too). Even when we factor in moving targets, if the PTV encompasses the motion (ITV), over multiple fractions this evens out... moving targets (moving target voxels more specifically) are as likely to "see" overdose as underdose when fluences are inhomogenous. Also, alignment to any particular nearby "anatomic fiducial" (ie aligning to spine in an esophageal case) is not guaranteed infaust, will vary in effectiveness from patient to patient (may be a good alignment in some cases), and again will be dependent on PTV margin choice (so that the CTV+/-GTV will be correctly dosed).

 

[Palex80]

Write back to them saying that you had to do 3DCRT since protons were not available...

 

[Palex80]

I resisted commenting but IMRT will in and of itself never underdose a target. Never. A human (rad onc) can, via inadequate PTV coverage. Everything that can or can't happen re: 3DCRT can happen w/ IMRT and vice versa (inadequate PTVs "hurt" 3DCRT too). Even when we factor in moving targets, if the PTV encompasses the motion (ITV), over multiple fractions this evens out... moving targets (moving target voxels more specifically) are as likely to "see" overdose as underdose when fluences are inhomogenous. Also, alignment to any particular nearby "anatomic fiducial" (ie aligning to spine in an esophageal case) is not guaranteed infaust, will vary in effectiveness from patient to patient (may be a good alignment in some cases), and again will be dependent on PTV margin choice (so that the CTV+/-GTV will be correctly dosed).

Nicely summarized.

Look up "interplay effect".

 

[nkmiami]

I resisted commenting but IMRT will in and of itself never underdose a target. Never. A human (rad onc) can, via inadequate PTV coverage. Everything that can or can't happen re: 3DCRT can happen w/ IMRT and vice versa (inadequate PTVs "hurt" 3DCRT too). Even when we factor in moving targets, if the PTV encompasses the motion (ITV), over multiple fractions this evens out... moving targets (moving target voxels more specifically) are as likely to "see" overdose as underdose when fluences are inhomogenous. Also, alignment to any particular nearby "anatomic fiducial" (ie aligning to spine in an esophageal case) is not guaranteed infaust, will vary in effectiveness from patient to patient (may be a good alignment in some cases), and again will be dependent on PTV margin choice (so that the CTV+/-GTV will be correctly dosed).

Sometimes, I have staff argue that setup/immobilization/image guidance should be different based on IMRT/3D and try to point this out.

 

[SneakyBooger]

I wouldn't be so quick to argue for the insurance companies. Yes, there are docs that do increase the cost of health care, the insurance company only goal is to make a profit and not provide the best health care services available.

Exactly, the insurance company is only in it to make money and lots of it.

Same goes for the "peers" that work for them.

Recently treated a lawyer who works for an insurance company and he said never for one minute think the insurance company is in it for anything else other than money.

 

[Neuronix]

Same goes for the "peers" that work for them.

I don't think that anyone ever aspires to peer review. Well, except maybe the one resident I had who fetishized the idea that after he graduated he might be able to tell the attendings he disliked "NO" to what he considered some of their weird or financially motivated practices.

That written, the three rad oncs I've known who have worked as peer reviewers were basically forced into it by being unemployable as a rad onc by a bad job market and/or non-compete. You have to put food on the table sometimes...

 

[OTN]

Exactly, the insurance company is only in it to make money and lots of it.

Same goes for the "peers" that work for them.

Recently treated a lawyer who works for an insurance company and he said never for one minute think the insurance company is in it for anything else other than money.

We should never expect any company to be in it for anything else other than money. That's what corporations are for. If they weren't they wouldn't be fulfilling their fiduciary responsibility to their shareholders.

 

[thecarbonionangle]

Medicare for all!

 

[SneakyBooger]

We should never expect any company to be in it for anything else other than money. That's what corporations are for. If they weren't they wouldn't be fulfilling their fiduciary responsibility to their shareholders.

Exactly.

And there are alternatives to Wall Street ethics.