IMRT for Stage III lung now considered medically necessary by Evilcore

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Burt Radnolds

Burt Radnolds

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radmonckey said:
This is a PSA I suppose. The title says it all. Just saw in their updated guidelines as of 9/21/20 that IMRT is covered for all Stage III lung. This is a very significant change from their previous wording.

Click to expand...

And in return they have mandated max of 28 treatments for all prostate cancers that are not treating lymph nodes.

Evicore giveth, and Evicore taketh away.

All hail our insurance overlords who dictate clinical practice.

Glad to see IMRT as necessary for stage III lung I guess.
 
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radmonckey said:
This is a PSA I suppose. The title says it all. Just saw in their updated guidelines as of 9/21/20 that IMRT is covered for all Stage III lung. This is a very significant change from their previous wording.

Click to expand...
The History of IMRT for lung cancer
~2003: Academic rad onc: You can not do IMRT for lung, it is not safe
~2005: Medicare: IMRT is not allowed for lung
~2007-10: Got gating? You can only do lung IMRT with gating or it is not safe.
~2010: Maybe we don't need gating in every case.
~2014: Insurances: IMRT for lung is nigh experimental. Do extra work, show me your work, blah blah.
~2020: Lung IMRT is medically necessary.

Thanks for all that, y'all.
 
Mandelin Rain said:
I got into residency during the "IMRT is not safe era." Apparently it was safer to miss 25-50% of the tumor during the off cord boost. Hey, at least it got 3600 cGy....
Click to expand...
The problem with that was: well hell if you're doing something that's not safe you must be some kind of criminal or money-gouging radiotherapeutic carpet-bagger. And how could you retort? "Well, I just like IMRT. It seems pretty neat! My patients are doing better, I promise." Anyways.
 
scarbrtj said:
The History of IMRT for lung cancer
~2003: Academic rad onc: You can not do IMRT for lung, it is not safe
~2005: Medicare: IMRT is not allowed for lung
~2007-10: Got gating? You can only do lung IMRT with gating or it is not safe.
~2010: Maybe we don't need gating in every case.
~2014: Insurances: IMRT for lung is nigh experimental. Do extra work, show me your work, blah blah.
~2020: Lung IMRT is medically necessary.

Thanks for all that, y'all.
Click to expand...
2017

So basically evicore is 3 years behind
 
Apparently IMRT for intact pancreas didn’t make the cut. Had to do that dance with evicore this week.
 
evilbooyaa said:
And in return they have mandated max of 28 treatments for all prostate cancers that are not treating lymph nodes.

Evicore giveth, and Evicore taketh away.

All hail our insurance overlords who dictate clinical practice.

Glad to see IMRT as necessary for stage III lung I guess.
Click to expand...
I'll take take trade-off any day of the week. You can thank the dinosaurs (both academic and PP) who are entirely unaware that prostate hypofractionation exists. Or even "hypofractionation" with 2Gy/fraction.
 
Straight from the pdf link posted above:

For stage III, definitive external beam radiation therapy to a dose of 60-70 Gy in 30-35 fractions using a 3D conformal technique or
intensity-modulated radiation therapy (IMRT) is considered medically necessary.
 
Radonc90 said:
Straight from the pdf link posted above:

For stage III, definitive external beam radiation therapy to a dose of 60-70 Gy in 30-35 fractions using a 3D conformal technique or
intensity-modulated radiation therapy (IMRT) is considered medically necessary.
Click to expand...
... but they say this in the end of the discussion

“However, as NCCN® that IMRT is preferred over 3DCRT for stage III, IMRT is also considered medically necessary.”

who knows?
 
Radonc90 said:
Straight from the pdf link posted above:

For stage III, definitive external beam radiation therapy to a dose of 60-70 Gy in 30-35 fractions using a 3D conformal technique or
intensity-modulated radiation therapy (IMRT) is considered medically necessary.
Click to expand...


"Medically necessary" doesn't mean its the only option, just that evilcore won't ride you a$s for choosing it.
 
The title of this thread is a bit misleading...

The title should have been "IMRT for Stage III lung cancer is now an option"...
 
Radonc90 said:
The title of this thread is a bit misleading...

The title should have been "IMRT for Stage III lung cancer is now an option"...
Click to expand...

The main issue most contemporary rad oncs have (prior to this) was getting IMRT approved for stage III NSCLC.

I'm not sure what the issue is. It's not mandating that you have to use IMRT. Do you still treat all stage III NSCLC with 3D?
 
In order to stay alive, breathing is necessary. In order to treat lung cancer, IMRT is not necessary. But “medically necessary” does not mean what necessary does, English word definition wise. This is medicolegal, insurance jargon. All medically necessary means is if it’s an (reasonable) option and the doctor chooses it, it’s medically necessary. Any option which is not reasonable is not medically necessary. Prior to this, Evicore was tacitly expressing that IMRT was an unreasonable option.
 
Any luck with Evicore and HA-WBRT in extensive stage SCLC patients with brain mets? I understand SCLC was excluded from NRG CC001 but doesn't seem to be any issues with increased hippocampal recurrences in the trial or other trials looking at SCLC and PCI. NCCN describes that it is as preferred in SCLC patients with life expectancy >4 months. How do you approach this even from a medical legal perspective if coverage is denied and the NCCN guidelines clearly state that it is preferred?
 
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I have not really tried b/c of the exclusion of SCLC in CC001. CC003 will give us an answer.

If you feel strongly about it, do p2p, and document the reviewer and hteir specialty in medical chart, stating that you cannot give your prescribed therapy beccause of insurance. I would, personally, not feel this is the hill to die on.
 
Unfortunately CC003 wont give us an answer either since that study is for patients without brain mets (PCI).
 
You'll have your answer with the next NRG study that is for SCLC brain mets. I believe it's up to 9 or 10 brain mets with size limits. The arms are HA-WBRT vs. SRS. I believe it's currently in the works at CTEP/CTSU level currently.

In the meantime, I treat HA-WBRT for SCLC. I haven't run into insurance difficulties, but I agree sometimes insurance dictates care and I don't know what to do about it except tell the patient their options when insurance denies my preferred option.
 
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