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TheWallnerus

TheWallnerus

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ASTRO attempting to destroy an entire company. I guess.

Proposed LCD - Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) (DL40179)

Use this page to view details for the Local Coverage Determination for Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC).
www.cms.gov www.cms.gov


 
US guided superficial photon completely bogus IMO and in the hands of derm leads to stupid overutilization, cost and at times excess toxicity.

Just my experience (also, the image guidance is not used to guide Dosimetry).

23k à pop for 20 fraction for lesions that could be locally excised or even cryo’d.
 
TheWallnerus said:
ASTRO attempting to destroy an entire company. I guess.

Proposed LCD - Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) (DL40179)

Use this page to view details for the Local Coverage Determination for Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC).
www.cms.gov www.cms.gov


Click to expand...
ASTRO the broken clock is right twice a day. Enjoy this rare opportunity, ASTRO
 
TheWallnerus said:
ASTRO attempting to destroy an entire company. I guess.

Proposed LCD - Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) (DL40179)

Use this page to view details for the Local Coverage Determination for Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC).
www.cms.gov www.cms.gov


Click to expand...
After skimming the transcript, I now suspect Jacob Scott owns a lot of Sensus stock.

* I’m kidding

Someone said in the transcript if a derm can predict depth to within 1 mm of accuracy versus ultrasound , what is the ultrasound buying you? Kind of hard to argue with that.

like protons, CMS should just fund a randomized trial and figure it out. US-IGSRT vs regular SRT and be done with the debate.
 
TheWallnerus said:
ASTRO attempting to destroy an entire company. I guess.

Proposed LCD - Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC) (DL40179)

Use this page to view details for the Local Coverage Determination for Superficial Radiation Therapy (SRT) for the Treatment of Nonmelanoma Skin Cancers (NMSC).
www.cms.gov www.cms.gov


Click to expand...
What a bizarre conversation in that transcript. A bunch of rad oncs rolling over agreeing that surgery oncologically better for skin cancer.
 
temujim said:
What a bizarre conversation in that transcript. A bunch of rad oncs rolling over agreeing that surgery oncologically better for skin cancer.
Click to expand...
Totally rolling over; who knew that surgery should always be the first option for skin cancer. And yet again the rad oncs nipping at each other and leaving a miasma of uncertainty behind for the policymakers.
 
TheWallnerus said:
Totally rolling over; who knew that surgery should always be the first option for skin cancer. And yet again the rad oncs nipping at each other and leaving a miasma of uncertainty behind for the policymakers.
Click to expand...

I thought they waffled too much on cosmesis too.

Wish we had trials but could we not figure out a way to get a million pics and have patients or general public rate them?

I can't tell you how many skin cases I get a year where the patients are refusing another Moh's because of scars. THe majority of my skin cases are derm referrals from patients that refuse to get another Moh's.

My takeaway/stance was...

- SRT is a first line option for skin cancer
- IG-SRT needs to run a trial to determine if the cost benefit has any clinical benefit before we pay for it
- cosmesis in many cases is superior with radiation and this is an important feature of this modality. If IG-SRT can minimize radiation target size (questionable). it is theoretically possible to further improve cosmesis, but we need a trial.
 
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Gfunk6 said:
This is all well and good, but consider the source. ASTRO has waffled so often and so vigorously that they would have been better off sending CMS a roll of Charmin rather than this LCD revision.
Click to expand...
ASTRO is first and foremost a political organization. Priorities for political groups are always context dependent. In our case, radiation is always the answer if we are delivering it. But the same treatment is ethically dubious if another specialty is profiting instead.
 
ramsesthenice said:
ASTRO is first and foremost a political organization. Priorities for political groups are always context dependent. In our case, radiation is always the answer if we are delivering it. But the same treatment is ethically dubious if another specialty is profiting instead.
Click to expand...
ASTRO PAC was willing to kill the in office ancillary exemption for ALL rad oncs in this country to stick to the GUs and rad oncs that dared partner together a few decades ago to start up urorads practices.

You're absolutely correct.
 
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IMO that SRT company is engaging in plain coding abuse... don't they also bill simple sim for each fraction?
 
A_DeMichele said:
IMO that SRT company is engaging in plain coding abuse... don't they also bill simple sim for each fraction?
Click to expand...
In my heart and soul I agree. But there are about 400 of these centers nationwide now either significantly affiliated with the company or using their tech. They have been audited by Medicare many times, no significant negative outcomes (evidently). To paraphrase an old saying, coding is codified by the winners.
 
TheWallnerus said:
In my heart and soul I agree. But there are about 400 of these centers nationwide now either significantly affiliated with the company or using their tech. They have been audited by Medicare many times, no significant negative outcomes (evidently). To paraphrase an old saying, coding is codified by the winners.
Click to expand...
I am starting to see them lose private payor contracts over the image guidance charge though.

Not sure the legality of this one, but I have seen them take cash pay for the image guidance, then insurance pays for the other codes.
 
BobbyHeenan said:
I am starting to see them lose private payor contracts over the image guidance charge though.

Not sure the legality of this one, but I have seen them take cash pay for the image guidance, then insurance pays for the other codes.
Click to expand...
That is typically a violation of the contract with the insurance company. Of course I don't know how their specific contracts are worded, but I doubt they have a carve out for this.
 
Tigerstang said:
That is typically a violation of the contract with the insurance company. Of course I don't know how their specific contracts are worded, but I doubt they have a carve out for this.
Click to expand...

That was my impression too.

Though this is from a patient, so I obviously didn't dive deeper. But the patient told me "the insurance wouldn't cover the ultrasound part, so they said I could pay cash for that." And he said it was around $1,500. So he asked for a referral to someone else and ended up seeing me.
 
It's also a violation of basic medical and business ethics. So you adapt the energy daily as the lesion shrinks on ultrasound. You are trying to spare a few mm of skeletal muscle a few extra Gray why exactly? When the patient inquires about that out of pocket charge, really, what are you going to say?

This is the medical version of William H Macy selling the TruCoat rust coating in Fargo.
 
alwaysbeIMRTing said:
It's also a violation of basic medical and business ethics. So you adapt the energy daily as the lesion shrinks on ultrasound. You are trying to spare a few mm of skeletal muscle a few extra Gray why exactly? When the patient inquires about that out of pocket charge, really, what are you going to say?

This is the medical version of William H Macy selling the TruCoat rust coating in Fargo.
Click to expand...

That was literally the argument I was seeing for the benefit from the rad oncs in that transcript. You can shrink margins and it will help with "tissue sparing" or cosmesis because of better visualization.

That may matter in some very delicate areas...but not for your routine case.
 
alwaysbeIMRTing said:
So you adapt the energy daily as the lesion shrinks on ultrasound
Click to expand...
Do they do this even? Gentle Cure does not even adapt energy per my understanding.

What's the uncertainty for depth determination for U/S?

Also, for Gentle Cure (50kV-200kV photons) the idea that you would adjust energy based on shrinkage is kinda funny. They prescribe to the surface.

1750104201550.png


Physics yo!
 
I have some oceanfront property on Mars to sell you if you actually believe they are changing anything daily, but that is the claim. It's a grift that makes chiropractors blush.

The first thing rad oncs learn in training is what GTV, CTV, and PTV are. Somehow I think they missed the first day of orientation:


"Full dermal visualization of the constantly changing NMSC tumor depth throughout therapy allows the dermatologist and radiation therapist to make compensatory adjustments (in kV, TDF and dose) in real time prior to every dose delivered."

"Tumor depth is constantly changing. This pattern of constant change is not predictable, so depth measurements must be repeated prior to each fraction of radiation given. In the absence of the ability to monitor depth changes prior to each fraction (treatment, dose given), the clinician cannot gauge when the tumor has reached a maximal depth that requires a compensatory adjustment in energy (kV) or TDF (or both), which could put the patient at risk for incomplete tumor clearance and recurrence. Without IGSRT, the ability to achieve a 99% cure rate for the BCC or SCC is lost."

Insane.
 
The simple solution here IMO would be to lobby for a different billing code for ultrasound-based image guidance that IGSRT uses, and set the RVUs/charges appropriately
 
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