Has insurance auth gone insane lately?

[Neuronix]

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2025 so far has been crazy for me.

All sorts of things that used to be automatically approved for me are all of a sudden requiring prior auths and peer to peers.

The final straw is the prior auth request I got this morning for dexamethasone in a patient with symptomatic brain metastases. 😵

 

[Gfunk6]

I usually get heartburn when I think about prior auth, but this year has been . . . ok? In fact, I've given a couple of patients the "abandon all hope" preamble about getting their radiation approved. Surprisingly they were approved without even an Evil-Corp "fill in the blanks" form.

This has not been the historic norm for me and I'm not holding my breath that it will continue . . .

 

[Lamount]

I feel like this happens to me every few months. Like things go well for a while and then... all-of-a-sudden, two patients with SCLC have p2p requests on surveilance brain MRI. Would guess they are systematically testing us, like the raptors testing the cages in Jurassic Park -looking for any points of weakness.

 

[ramsesthenice]

2025 so far has been crazy for me.

All sorts of things that used to be automatically approved for me are all of a sudden requiring prior auths and peer to peers.

The final straw is the prior auth request I got this morning for dexamethasone in a patient with symptomatic brain metastases. 😵

100%. I've had to jump through hoops 4 times this year to get IMRT for intact prostate cancer. WTF?

 

[Palex80]

The final straw is the prior auth request I got this morning for dexamethasone in a patient with symptomatic brain metastases. 😵

So, how much would the dexamethasone treatment cost and how much did the prior authorisation procedure cost for this patient?

 

[ramsesthenice]

So, how much would the dexamethasone treatment cost and how much did the prior authorisation procedure cost for this patient?

I’ve thought to myself many times, why can’t hospital systems or private groups sue PA servicers for frivolous requests which run counter to widely accepted standard practice guidelines? The cost of these things ends up being enormous and there is no question we are shouldering the administrative costs to get approval for services we all know will get approved. I’m not talking about protons or MRIGRT. Really basic stuff like IMRT for prostate.

 

[medgator]

So, how much would the dexamethasone treatment cost and how much did the prior authorisation procedure cost for this patient?

It's generic. Makes zero sense to me

My PA requests have been ok lately.

 

[madchemist89]

Are you telling me that some insurers are requiring you to treat prostate 3D?

 

[BobbyHeenan]

100%. I've had to jump through hoops 4 times this year to get IMRT for intact prostate cancer. WTF?

Stage 4 cases or a run of the mill localized only int risk case?

In a decade I’ve never had an Imrt prior with for a prostate case unless someone in the auth dept coded something wrong (like coded a high risk as stage 4 on the auth form).

If this is happening now then my goodness…definitely would have merit for a suit.

 

[ramsesthenice]

Are you telling me that some insurers are requiring you to treat prostate 3D?

No, they are not requiring it. They of course approve it. They are just using it as a way to try to worm out of paying for something standard. To be more clear, they are not hanging it up at PA. This particular issue they are trying to deny after we started by requesting a LON. Which of course is unreal.

Stage 4 cases or a run of the mill localized only int risk case?

In a decade I’ve never had an Imrt prior with for a prostate case unless someone in the auth dept coded something wrong (like coded a high risk as stage 4 on the auth form).

If this is happening now then my goodness…definitely would have merit for a suit.

We are talking about non metastatic run of the mill cases. It’s wild.

 

[OTN]

Insurer denied SRS for a solitary small cell brain met. I appealed with the FIRE-SCLC study. They took so long to approve we had to get another brain MRI, come up with another plan, etc. Ended up costing them several thousand dollars more than if they had just approved.

 

[medgator]

Insurer denied SRS for a solitary small cell brain met. I appealed with the FIRE-SCLC study. They took so long to approve we had to get another brain MRI, come up with another plan, etc. Ended up costing them several thousand dollars more than if they had just approved.

I did have an insurer recently deny sbrt for an early stage sclc. Would only approve 30-35 FX of 3D/igrt. Hard stop

Costs them way more to give that older treatment. More inconvenience for the patient. But who cares 🤷🏾

They DGAF about nccn guidelines

 

[fiji128]

I recently Rx'ed lupron 45mg injection for a high risk prostate cancer. The CVS PBM wouldn't approve it and insisted that the Rx be for specifically for only Eligard 45mg instead. I have never had something like this happen before, what an absolute waste of time for everyone involved.

 

[BobbyHeenan]

I recently Rx'ed lupron 45mg injection for a high risk prostate cancer. The CVS PBM wouldn't approve it and insisted that the Rx be for specifically for only Eligard 45mg instead. I have never had something like this happen before, what an absolute waste of time for everyone involved.

I’ve run into that one a number of times unfortunately. Some combo of location of site of injection (hospital or infusion center or clinic) and insurance it could be Lupron or Eligard and I never know. It’s a mess.

 

[medgator]

I recently Rx'ed lupron 45mg injection for a high risk prostate cancer. The CVS PBM wouldn't approve it and insisted that the Rx be for specifically for only Eligard 45mg instead. I have never had something like this happen before, what an absolute waste of time for everyone involved.

Drug pricing I'm guessing

 

[SneakyBooger]

2025 so far has been crazy for me.

All sorts of things that used to be automatically approved for me are all of a sudden requiring prior auths and peer to peers.

The final straw is the prior auth request I got this morning for dexamethasone in a patient with symptomatic brain metastases. 😵

Skip P2P and go straight to appeal. P2P is a waste of time. Write strong letter and don't be nice. If still denied instruct patient to request external review. I have had 2 patients over past 5 yrs have to request external review and treatment was approved prior to having to obtain external review.

 

[Ray D. Ayshun]

Has anyone had luck getting SRS approval for solitary brain met in Small cell? guidelines continue to specifically forbid.

 

[WildRivers]

Has anyone had luck getting SRS approval for solitary brain met in Small cell? guidelines continue to specifically forbid.

Don’t remember any recent denials. This is bat**** crazy.

 

[medgator]

Has anyone had luck getting SRS approval for solitary brain met in Small cell? guidelines continue to specifically forbid.

Haven't had a problem. I thought nccn guidelines allowed SRS

 

[Ray D. Ayshun]

Don’t remember any recent denials. This is bat**** crazy.

Just Checking preemptively as someone above mentioned it. Evicore still specifically excludes small cell in their guidelines. Nccn doesn't really explicitly endorse per se. Moreso after prior whole brain

 

[TheWallnerus]

UHC guidelines now allow

There were LCDs that didn’t allow, I think all do now

 

[radoncftw]

I have not had an issue getting SRS approved for small cell in the past 1-2 years

 

[drowsy12]

2025 so far has been crazy for me.

All sorts of things that used to be automatically approved for me are all of a sudden requiring prior auths and peer to peers.

The final straw is the prior auth request I got this morning for dexamethasone in a patient with symptomatic brain metastases. 😵

Did you move locations?

 

[Ray D. Ayshun]

I have not had an issue getting SRS approved for small cell in the past 1-2 years

I haven't either, but this is evicore

 

[Neuronix]

Did you move locations?

Since that post, yes

 

[drowsy12]

Since that post, yes

Oh got it, I was more asking if it was new issues from insurance in a new location, which has happened before

Never mind!

 

[Neuronix]

Oh got it, I was more asking if it was new issues from insurance in a new location, which has happened before

Never mind!

Nah, it's the opposite here. My new job provides robust prior auth and peer review support. I have had to do much less in this regard since moving.