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ramsesthenice

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Just got a denial for SBRT or even IMRT for a patient with a history of prostate cancer presenting with a single painful met to T5. No other sites of disease. On its face, I would say I am not surprised but the physician doing the peer-to-peer went on to tell me they only approve SBRT or IMRT for isolated bone mets for breast, lung, or melanoma but not prostate. Are they flipping coins to decide what level of evidence is enough? So frustrating. I don't know about anyone else but the number of peer-to-peers I am doing has skyrocketed recently. Evicore had us do a comparative plan to get approval for IMRT for a definitive pancreas case last week :mad:
 
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Just got a denial for SBRT or even IMRT for a patient with a history of prostate cancer presenting with a single painful met to T5. No other sites of disease. On its face, I would say I am not surprised but the physician doing the peer-to-peer went on to tell me they only approve SBRT or IMRT for isolated bone mets for breast, lung, or melanoma but not prostate. Are they flipping coins to decide what level of evidence is enough? So frustrating. I don't know about anyone else but the number of peer-to-peers I am doing has skyrocketed recently. Evicore had us do a comparative plan to get approval for IMRT for a definitive pancreas case last week :mad:

Please send this example to ASTRO, ACRO, etc.

I know they are big into lobbying aginst this behavior by insurance.

I don't know what they will accomplish, but have to make sure our dues go to some good use
 

medgator

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Just got a denial for SBRT or even IMRT for a patient with a history of prostate cancer presenting with a single painful met to T5. No other sites of disease. On its face, I would say I am not surprised but the physician doing the peer-to-peer went on to tell me they only approve SBRT or IMRT for isolated bone mets for breast, lung, or melanoma but not prostate. Are they flipping coins to decide what level of evidence is enough? So frustrating. I don't know about anyone else but the number of peer-to-peers I am doing has skyrocketed recently. Evicore had us do a comparative plan to get approval for IMRT for a definitive pancreas case last week :mad:
Kinda like evicore deciding the only lung cancer cases that deserve IMRT upfront without a plan comparison are patients with N3 disease or superior sulcus involvement (they finally changed their guidelines earlier this year, but until then, it was a 3D plan comparison for every stage III lung).
 
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DebtRising

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Pretty common now for sbrt to be approved or denied tied to primary histology where I practice. Prostate is not on a number of lists in this regard. Also get denials for the Stampede regimen with Horrad as the response.
 

scarbrtj

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Needless to say it is very favorable to the soul if one practices in a place where one can still give the treatment one wants/knows is right without 1) fear of someone saying it’s fraud (ie billing simple but doing SBRT etc), or 2) flat out prohibited. I’d lose sleep if I were there. And I’ve been there.
 
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Neuronix

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My "favorite" Evilcore reviewer rejected me for a pancreas cancer single met in mid spine involving most of vertebral body, painful. Controlled primary disease. Unusual case I know, but there it was. I appealed it and it was shot down again.

Reason given? Pancreas cancer is not a radioresistant histology. Seriously? Pancreas isn't radioresistant on what planet?

Guidelines only support sarcoma, melanoma, or RCC as those are radioresistant.

So instead of 16 - 18 Gy / 1 fraction I did 30 Gy in 10 fractions. Patient inconvenienced, dose probably less effective, patient with some temporary esophagitis from treatment as opposed to no side effects.

I don't know how these "reviewers" can live with themselves.
 

radiaterMike

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Not sure how far up you took the appeal. After the Evicore denial you can go to the insurer, and after that (in some states) you can seek independent review. You can use ASTRO model policy for SBRT as justification of SBRT for spine metastases (along with innumerable publications).

The Evicore reviewer may not disagree with you, but still needs to follow their guidelines. The insurer can overturn the denial at their discretion. Independent review is not tied to Evicore, but rather 'medical necessity'
 
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Mandelin Rain

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Not sure how far up you took the appeal. After the Evicore denial you can go to the insurer, and after that (in some states) you can seek independent review. You can use ASTRO model policy for SBRT as justification of SBRT for spine metastases (along with innumerable publications).

The Evicore reviewer may not disagree with you, but still needs to follow their guidelines. The insurer can overturn the denial at their discretion. Independent review is not tied to Evicore, but rather 'medical necessity'
With a painful bone met, it's hard to wait to file multiple appeals.
 
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Neuronix

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Not sure how far up you took the appeal. After the Evicore denial you can go to the insurer, and after that (in some states) you can seek independent review.

Insurers have always just sent us right back to NIA/Evilcore. Only once we were able to have the insurer look into the case, and that's because it was a police officer we were treating and someone high up in the county called to the insurance company to start pulling strings.

I didn't know about the independent review, but nowadays I am requesting our staff and the patient to file an emergency review request when the patient is denied for something I think is indicated and the patient really wants. I'm not sure that we've actually gone through with it, but I'm itching to try it.

You can use ASTRO model policy for SBRT as justification of SBRT for spine metastases (along with innumerable publications).

They never want to discuss the data. I know the data for CNS very well.

The Evicore reviewer may not disagree with you, but still needs to follow their guidelines. The insurer can overturn the denial at their discretion. Independent review is not tied to Evicore, but rather 'medical necessity'

It was Cigna in this case and if you try to talk to them they send you straight back to Evilcore.
 
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medgator

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Insurers have always just sent us right back to NIA/Evilcore. Only once we were able to have the insurer look into the case, and that's because it was a police officer we were treating and someone high up in the county called to the insurance company to start pulling strings.

I didn't know about the independent review, but nowadays I am requesting our staff and the patient to file an emergency review request when the patient is denied for something I think is indicated and the patient really wants. I'm not sure that we've actually gone through with it, but I'm itching to try it.



They never want to discuss the data. I know the data for CNS very well.



It was Cigna in this case and if you try to talk to them they send you straight back to Evilcore.
Cigna esp terrible
 
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radoncgrad2019

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Needless to say it is very favorable to the soul if one practices in a place where one can still give the treatment one wants/knows is right without 1) fear of someone saying it’s fraud (ie billing simple but doing SBRT etc), or 2) flat out prohibited. I’d lose sleep if I were there. And I’ve been there.

exactly what I do. If I want to give SBRT badly
Enough, I do it, and accept 3D or IMRT, wharver they give me.
 
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scarbrtj

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exactly what I do. If I want to give SBRT badly
Enough, I do it, and accept 3D or IMRT, wharver they give me.
ASTRO needs to come out in support of this being OK and acceptable, clearing the field of all these billing and coding and admin types who say that doing something high-dollar and billing it low-dollar is fraud. What I really can't stand is when a biller says this with a wry smile, leans back in the chair, and goes "Doing IMRT and billing it as 3D is technically illegal, you know"... so proud of their accomplishment, ability to do the right thing, etc.
 
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radoncgrad2019

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I do think doing IMRT and billing 3D is a bit more tricky.

With SBRT - Every SBRT plan is also by definition ALSO a 3D or IMRT plan. So you can easily accept 3D or IMRT depending on which technique the planners use and still feel like it’s reasonable IMO.
 

scarbrtj

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I do think doing IMRT and billing 3D is a bit more tricky.

With SBRT - Every SBRT plan is also by definition ALSO a 3D or IMRT plan. So you can easily accept 3D or IMRT depending on which technique the planners use and still feel like it’s reasonable IMO.
Semantics! "IMRT is the advanced form of 3D-CRT."
I'm gonna hate APM when it comes 'cause I'll be a little more poor.
But I'm gonna be a hell of a lot more sane.
 
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ramsesthenice

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Pretty common now for sbrt to be approved or denied tied to primary histology where I practice. Prostate is not on a number of lists in this regard. Also get denials for the Stampede regimen with Horrad as the response.

Its a crap shoot. I know for BCBS, I can get SBRT for prostate bone mets but not nodal mets. For some, I can't get it for anything. I just can't figure out how they come up with their lists.

Needless to say it is very favorable to the soul if one practices in a place where one can still give the treatment one wants/knows is right without 1) fear of someone saying it’s fraud (ie billing simple but doing SBRT etc), or 2) flat out prohibited. I’d lose sleep if I were there. And I’ve been there.

Yep. I usually just bill per plan and do what I think is best for the patient. I have never been fussed at from above so we will just keep it at that.

Not sure how far up you took the appeal. After the Evicore denial you can go to the insurer, and after that (in some states) you can seek independent review. You can use ASTRO model policy for SBRT as justification of SBRT for spine metastases (along with innumerable publications).

The Evicore reviewer may not disagree with you, but still needs to follow their guidelines. The insurer can overturn the denial at their discretion. Independent review is not tied to Evicore, but rather 'medical necessity'

They have us by the sack and they know it. They are like a shady retailer who knows that the cost and hassle of going to small claims court is more trouble than its worth for most people. I wish it were different but in most cases I fall solidly into the "aint nobody got time for that" camp.
 
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scarbrtj

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I just don't understand why Evicore employs bottom of the barrel docs as reviewers. No offense to FMG's in general, but for a doc who trained IM in a foreign country and practiced cosmetic medicine and pain management to be doing radiation oncology reviews is crazy.
Evicore only uses/hires BC rad oncs. And docs who maintain rad onc certification. Did their residency at good places. (And all I’ve ever spoken to sounded very American, although a few are FMGs.) This is their main cover for authority in dealing with other rad oncs to deny care.
 
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scarbrtj

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There are plenty of unemployed and underemployed rad oncs to go around for Evilcore to choose from. I got denied by one of my residency attendings awhile back. For other specialties it's different.
I have had several "friends" deny me lol. Evicore offers about $250K/yr for 40 hrs/week, plus very good benefits. And it's 100% work from home. Over time you can move up in the ranks a bit, make more. The top rad onc at Evicore I would guess makes $500-750K per year. This guy doesn't like hiring docs who like to approve a lot of things.
 
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RickyScott

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Evicore only uses/hires BC rad oncs. And docs who maintain rad onc certification. Did their residency at good places. (And all I’ve ever spoken to sounded very American, although a few are FMGs.) This is their main cover for authority in dealing with other rad oncs to deny care.
Know of docs at evicore who trained at MSKCC and Yale.
 
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Mandelin Rain

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DISCLAIMER: I'm sure they do catch and appropriately deny a lot of wasteful/borderline fraudulent treatments. That's good. I'm not sure how much of what they do is this vs. denying completely reasonable/standard of care measures like IMRT/IGRT for stage III lung cancer or pancreas cancer. My guess is it's a lot more of the latter (Florida being a possible exception). That guess informs my feelings on them.

RANT: On the measure, I think these are people to be disdained. They have sold their souls (for a quarter million dollars) to a heartless corporation and deny care for our patients that they themselves would demand. They should be treated with scorn within our community.
 
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scarbrtj

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Of all the delusions of grandeur we fantasize over on this board, I have always wanted to start a website where we could post recordings of the calls we have with these reviewers. Nowadays it's very easy for a cellphone to make an MP3 of any phone call e.g. Some of my interactions have been truly Kafkaesque, "Who's on first?"* type interactions... high comedy.

* like... everyone gets this reference, right
 
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radiaterMike

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In defense of these Evicore RadOncs (and I am not one of them and I don't think I know any personally), they must base their decision on the policy, which is based on NCCN guidelines, ASTRO model policies, published literature etc. As Mandelin Rain states, many (most?) of their denials are probably justifiable (i.e. IMRT for routine palliation of bone metastases). Sometimes the denials are based on controversial treatments (SBRT for high risk prostate cancer, proton therapy routine breast or prostate cases, etc). As we all know, Evicore policies can be very limited, particularly where little data exist, or NCCN guidelines are not 'firm'. This is what creates the frustration on our field. Evicore is not an insurer, and you can take your case to them. I know this does not always work either. APM might be the answer. Hopefully it doesn't bankrupt the field though.
 
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scarbrtj

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DISCLAIMER: I'm sure they do catch and appropriately deny a lot of wasteful/borderline fraudulent treatments. That's good. I'm not sure how much of what they do is this vs. denying completely reasonable/standard of care measures like IMRT/IGRT for stage III lung cancer or pancreas cancer. My guess is it's a lot more of the latter (Florida being a possible exception). That guess informs my feelings on them.

RANT: On the measure, I think these are people to be disdained. They have sold their souls (for a quarter million dollars) to a heartless corporation and deny care for our patients that they themselves would demand. They should be treated with scorn within our community.
A peek under the Evicore hood:

The wild-n-crazy stuff, eg 50/25 for a bone met, gets screened out by nurses/RNs before it ever hits the MD's LCD monitor. Those are hard no's... the overt cash grabs etc. I am pretty sure Evicore has a 10-fraction limit for bone mets. So if you wanna do 50/25, hard no, see ya. But 30/12? That's gonna get an MD review. If you look in the Evicore manual, there are "hard no's" and then a lot of "will be on a case by case basis." This is where the data has only whispered benefit, where OS has maybe only shown a little leg, versus screamed benefit at the top of its lungs. These will be the purview of the Evicore MD reviewer, the ones where the "appellant" (you and me) is going to the "judge" (Evicore) for a ruling. On the blatant bad ones, no one is having a phone call review. The judge would laugh those out of court. But here's the takeaway: the Evicore MD reviewers are spending 99% of their time making 50/50 calls, grey zone case calls, bias-y calls, etc. Look at the recent Supreme Court ruling on gay/transgender Title VII. Alito and Thomas were SURE the defendants were in the right. Gorsuch et al were sure they weren't. Me, I didn't see how it could not be argued the Gorsuch way. Evicore is over there with Alito et al twisting itself in verbal knots, or more invidiously, absolutely sure it's cloaking itself in cost-effective, proper care.
 
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scarbrtj

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Gotcha. Most of the P2P I've done, and I've only done a few, have been for things like MRI's for cervix cancer brachytherapy planning that get denied, not IMRT or radiotherapy per se.
Now the radiology guys.... yeah, they're all over the place. Very many are not BC radiologists.
 

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Now the radiology guys.... yeah, they're all over the place. Very many are not BC radiologists.

This is what happens when you have a decent job market. Good BC radiologists would laugh at 250k/year.
 
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Mandelin Rain

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I kind of assumed the peer-peer docs only get involved on the 50/50 stuff. There is a fair amount of hubris in thinking that you know better than the treating rad onc (who has seen, examined, questioned, reviewed the chart and all imaging of the patient in question) on these 50/50 indications. Hubris and/or the self-interested desire to maintain a quarter million in annual salary to deny them. Obviously for anything 50/50, it should default for treating physician's recommendation rather than phone physician in another state's recommendation. But that's not how record profits are achieved.
 
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Reaganite

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My favorite is when you do actually get that evicore auth the insurance still finds a way not to pay. 6 months post treatment and no payment..."oops, evicore never loaded the auth in our system, send us a copy of your auth." Fax and email auth, 1 month later still no payment. "OH, hmm, we never received the auth you were supposed to send." Send auth which they finally admit to receiving another month later. "Oh, we need medical records."
 
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medgator

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In defense of these Evicore RadOncs (and I am not one of them and I don't think I know any personally), they must base their decision on the policy, which is based on NCCN guidelines, ASTRO model policies, published literature etc.
The decision to allow IMRT only in N3 nsclc without a plan comparison reeks of cost containment and is not based on any data or guidelines I'm aware of.

Neither is the routine denial of IGRT for anything palliative
 

scarbrtj

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The decision to allow IMRT only in N3 nsclc without a plan comparison reeks of cost containment and is not based on any data or guidelines I'm aware of.

Neither is the routine denial of IGRT for anything palliative
Their guidelines are capricious and arbitrary on many an occasion.
Some are truly cooked out of thin air it seems.
But you know that one attending back in residency who had that one hang-up about that one thing, and he/she thought only he/she could do it the right way? And all the other conflicting data was off or wrong or whatever? I mean how many modern playwrights truly believe they're better than Shakespeare; quite a few I reckon. I remember Simul talking about how MDACC only does 5FU/cis (no MMC) for anal. MDACC thinks they know the best way! Evicore is just as confident in their approach, when they make it, as a place like MDACC is in theirs. There are guidelines. And there are Evicore guidelines.
 
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CaesarRO

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In defense of these Evicore RadOncs (and I am not one of them and I don't think I know any personally), they must base their decision on the policy, which is based on NCCN guidelines, ASTRO model policies, published literature etc. As Mandelin Rain states, many (most?) of their denials are probably justifiable (i.e. IMRT for routine palliation of bone metastases). Sometimes the denials are based on controversial treatments (SBRT for high risk prostate cancer, proton therapy routine breast or prostate cases, etc). As we all know, Evicore policies can be very limited, particularly where little data exist, or NCCN guidelines are not 'firm'. This is what creates the frustration on our field. Evicore is not an insurer, and you can take your case to them. I know this does not always work either. APM might be the answer. Hopefully it doesn't bankrupt the field though.
I've had a P2P in which I explicitly quoted NCCN and was told that they follow their internal guidelines, not NCCN.

I don't remember the specifics of the case now, but I was pretty incensed at the time at them basically turning down an NCCN endorsed option.
 
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evilbooyaa

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we can start naming them depending on forum rules?

No. We've had this discussion before, but the answer is still no, do not name individual reviewers, at minimum, in the public section of the site.

If there is significant interest to this in the private forum, we can have a discussion.
 

medgator

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No. We've had this discussion before, but the answer is still no, do not name individual reviewers, at minimum, in the public section of the site.

If there is significant interest to this in the private forum, we can have a discussion.
I think it should be fair game in the evilcore thread in the private forum
 

radiaterMike

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I've had a P2P in which I explicitly quoted NCCN and was told that they follow their internal guidelines, not NCCN.

I don't remember the specifics of the case now, but I was pretty incensed at the time at them basically turning down an NCCN endorsed option.

NCCN guidelines can be tricky. For example- they mention proton therapy as an option for NSCLC, but they do not advocate that PBT *should* be used in lieu of non-proton based RT. SBRT for NSCLC oligoprogression was not mentioned in NCCN guidelines until recently, and though it is now discussed, it probably will not be enough for insurers to accept it. IMRT for breast cancer is mentioned in NCCN guidleines, but the criteria for necessity are not, so insurers are sure to pick the cheaper standard option. SBRT for high-risk prostate cancer was explicitly not endorsed by NCCN, but the guidelines now state that it is considered acceptable if standard RT would "present a medical or social hardship" - but I'm guessing most policies will not have this language (and will simply consider it not necessary, despite being more cost effective than 8-9 weeks of IMRT). For HNC, proton therapy is considered "investigational", but may be considered when normal tissue constraints cannot be met -- but "either IMRT or proton therapy" is recommended for maxillary sinus or paranasal/ethmoid cancers. Guess which one (IMRT or proton therapy) insurers will pick (unless you can legitimately show protons are needed). So just because it is in NCCN guidelines as a possible option does not mean insurers will accept that. They do actually look at level of evidence.
 

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I hope there comes a time when we can simply pick the best plan/ fractionation/ modality for each case. I can careless what is paid for.

Maybe I'm naive or very new to all this, but it is very frustrating when you know there's a better solution to a problem and you can't do it because some old, retired, milked the system rad onc comes on the phone and wants to argue with you to submission.

There will never be any more innovation in this field if all we can choose from is a cookbook Evicore manual,
 

medgator

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I hope there comes a time when we can simply pick the best plan/ fractionation/ modality for each case. I can careless what is paid for.

Maybe I'm naive or very new to all this, but it is very frustrating when you know there's a better solution to a problem and you can't do it because some old, retired, milked the system rad onc comes on the phone and wants to argue with you to submission.

There will never be any more innovation in this field if all we can choose from is a cookbook Evicore manual,
This is why the freestanding community was pushing bundled payments over a decade ago. Afaik, Astro still isn't on board with site-neutral bundles
 
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