Is 5 Fraction Partial Breast Irradiation SBRT?

[radiation123]

ASTRO is developing new partial breast radiation guidelines. There is a draft of the new guidelines online and there is a comments period that ends on July 5th. In these guidelines, they have an accepted techniques section which does not include SBRT. I think 5 fractions partial breast radiation should be considered SBRT, if given with appropriate imaging, machine QA and physician/physics supervision. A 5 fractions IMRT plan would result in a significant decrease in reimbursement compared to a standard hypofractionated technique or conventional fractionation. However, a 5-fraction SBRT treatment would likely cause no significant change or a slight increase in reimbursement. ASTRO adding SBRT as an accepted technique would be a good first step in the process of getting insurance companies to accept partial breast radiation as SBRT.

If you agree that 5 fractions SBRT should be considered an accepted technique, please use the link below to let ASTRO know. The link to new guidelines and comments is below:

Public comment - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

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[radiation123]

I have attached the full comment that I submitted to ASTRO below if anyone wanted to see my full reasoning. Feel free to use as a template if you want.

Thank you for the excellent guidelines for partial breast irradiation, it is very well written and researched. I have only one request/suggestion that I hope you will consider. For the techniques for partial breast radiation, it would be helpful if you included SBRT as an accepted technique.

The Livi regimen is 30 Gy in 5 fractions and was delivered with IMRT. While this technique was not called SBRT in the paper, their regimen would qualify as SBRT in the US under AAPM task group 101 definition of SBRT: “the delivery of large doses in a few fractions, which results in a high biological effective dose BED.” With appropriate imaging, machine QA and physician/physics supervision, it would also meet the characteristics of SBRT as set forth in table 1 of that paper (Benedect et al, Med Phys 2010). The link for the paper is provided below. 25-30 Gy in 5 fractions are also already considered stereotactic radiation in other disease sites such as CNS.

For financial reasons, a five fraction IMRT partial breast treatment will likely not be widely adopted, however, a five fraction SBRT partial breast treatment would. It is difficult to quantify the exact decrease in revenues from switching due to differences in fractionation and variability in reimbursement by payor. However, if we use the numbers provided by Meeks et al in table 3 in the paper linked below switching to 5 fractions IMRT treatment would decrease reimbursement per patient for a 15-fraction 3D conformal plan, 15 fraction IMRT plan and a 25-fraction 3D plan by ~1,500 dollars, ~5,400 dollars, and ~5,800 dollars, respectively. In contrast a five fraction SBRT plan would change reimbursement per patient for a 15-fraction 3D conformal plan, 15-fraction IMRT plan and a 25-fraction 3D plan by ~+3,800 dollars, ~0 dollars and ~-400 dollars. Depending on the fractionation and number of breast patients seen, switching eligible patient to a 5-fraction IMRT treatment could decrease reimbursement by hundreds of thousands of dollars per provider per year. However, a 5-fraction SBRT treatment would likely cause no significant change or a slight increase in reimbursement. Only a minority of centers can afford to lose hundreds of thousands of dollars per radiation oncologist, and thus a 5-fraction IMRT regimen will likely not be accepted. However, a 5-fraction SBRT regimen would likely be adopted.

A five fraction IMRT regimen would likely also worsen inequalities as minority patients are disproportionally treated at hospitals with limited financial resources where a 5-fraction IMRT regimen would be unlikely to be adopted.

I am aware that adding SBRT as an accepted technique would not solve all reimbursement issues for partial breast radiation, but it would be a good first step. Many great academicians/trialists have expended tremendous effort to make partial breast irradiation a reality. It would be a shame if it was not widely adopted due to a billing/technique issue.



https://aapm.onlinelibrary.wiley.com/doi/epdf/10.1118/1.3438081

https://ascopubs.org/doi/pdf/10.1200/OP.21.00298?role=tab

 

[thecarbonionangle]

The argument you are trying to make to ASTRO is basically “come on help us out”, but it is unclear how receptive ASTRO elite “academics” are to these arguments. Many people in academics have no idea about billing or care about it. We all know it!
To care about this is to be “greedy” in many “academic” circles, ignoring the reality that in the end the mathematics need to work.
I agree with you. It is sad that the places that should offer this more (rural, transportation issues population) likely will not because they cannot keep the doors open.

 

[radiation123]

The argument you are trying to make to ASTRO is basically “come on help us out”, but it is unclear how receptive ASTRO elite “academics” are to these arguments. Many people in academics have no idea about billing or care about it. We all know it!
To care about this is to be “greedy” in many “academic” circles, ignoring the reality that in the end the mathematics need to work.
I agree with you. It is sad that the places that should offer this more (rural, transportation issues population) likely will not because they cannot keep the doors open.

I agree that in the past ASTRO has done a poor job advocating for appropriate reimbursement, and there is a strange distaste among academics to lobby for higher reimbursement. However, ultimately this change would be in the academic’s favor. Many academics have an RVU bonus, and even if they don’t, they may want to keep revenue coming into the department to not anger the higher ups.

My hope is that if enough people go and comment then it will give the academics moral cover to advocate for their/our interests. Basically, I want them to be able to say "We weren't greedy, we just had call it SBRT because of the pressure from the greedy community/private practice Rad Oncs". In this situation everyone would win, we would all get reimbursed fairly and the academics can keep their air of moral superiority.

 

[Fpg1245]

While I agree and have seen it billed this way, the sheer increase in SBRT volume from Brest alone may trigger massive cuts in reimbursement as a result because of increased utilization.

 

[CaesarRO]

In my part of the country insurance flatly refused to consider 5 fx apbi per Florence to be SBRT. While it's incredibly frustrating, the only thing I could agree with them on is that SBRT doesn't usually have a CTV or large CTV/PTV expansions. Florence does 1.5 + 1cm CTV and PTV.

If we were doing pre-op treatment with same fractionation to GTV + 5 or something I think we'd have a better case.

 

[grenz]

In my part of the country insurance flatly refused to consider 5 fx apbi per Florence to be SBRT. While it's incredibly frustrating, the only thing I could agree with them on is that SBRT doesn't usually have a CTV or large CTV/PTV expansions. Florence does 1.5 + 1cm CTV and PTV.

If we were doing pre-op treatment with same fractionation to GTV + 5 or something I think we'd have a better case.

Agree. You’re lacking the heterogeneity and tight margins that every other sbrt paradigm employs. If you’re concerned about the financials of partial breast, do IMPORT LOW. it’s the most evidenced based PBI regimen

 

[Fpg1245]

Maybe if breast imaging improves and non op management becomes a thing for early BC. SBRT breast tumor

 

[deleted1111261]

Agree. You’re lacking the heterogeneity and tight margins that every other sbrt paradigm employs. If you’re concerned about the financials of partial breast, do IMPORT LOW. it’s the most evidenced based PBI regimen

Bone sbrt doesn’t have heterogeneity (per Mdacc study, at least). Some pancreas has CTV for lower doses.

 

[TheWallnerus]

ASTRO is developing new partial breast radiation guidelines. There is a draft of the new guidelines online and there is a comments period that ends on July 5th. In these guidelines, they have an accepted techniques section which does not include SBRT. I think 5 fractions partial breast radiation should be considered SBRT, if given with appropriate imaging, machine QA and physician/physics supervision. A 5 fractions IMRT plan would result in a significant decrease in reimbursement compared to a standard hypofractionated technique or conventional fractionation. However, a 5-fraction SBRT treatment would likely cause no significant change or a slight increase in reimbursement. ASTRO adding SBRT as an accepted technique would be a good first step in the process of getting insurance companies to accept partial breast radiation as SBRT.

If you agree that 5 fractions SBRT should be considered an accepted technique, please use the link below to let ASTRO know. The link to new guidelines and comments is below:

Public comment - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

SBRT priced at about 1200 per fraction

IMRT priced at about 350 per fraction

It’s not going to be chicken feed difference

 

[thesauce]

If 3-5 fx with photons and over 4 Gy per fraction, then I usually consider it SBRT.

 

[TheWallnerus]

I agree that in the past ASTRO has done a poor job advocating for appropriate reimbursement, and there is a strange distaste among academics to lobby for higher reimbursement. However, ultimately this change would be in the academic’s favor. Many academics have an RVU bonus, and even if they don’t, they may want to keep revenue coming into the department to not anger the higher ups.

My hope is that if enough people go and comment then it will give the academics moral cover to advocate for their/our interests. Basically, I want them to be able to say "We weren't greedy, we just had call it SBRT because of the pressure from the greedy community/private practice Rad Oncs". In this situation everyone would win, we would all get reimbursed fairly and the academics can keep their air of moral superiority.

Private insurance will never accept this.

You can go ahead and bill this out as SBRT on Medicare patients now however. OTOH todays Medicare patient is tomorrows Medicare Advantage patient. And then we are back in same private insurance boat.

 

[thesauce]

Private insurance will never accept this.

You can go ahead and bill this out as SBRT on Medicare patients now however. OTOH todays Medicare patient is tomorrows Medicare Advantage patient. And then we are back in same private insurance boat.

Medicare Advantage is supposed to cover everything Medicare does at a minumum. They still deny some of those things but I believe it’s either illegal or violates their contract with Medicare (or both).

 

[Palex80]

If 3-5 fx with photons and over 4 Gy per fraction, then I usually consider it SBRT.

So, 3 x 6 Gy with a single pa field for a bone met in the lumbar spine is SBRT? 🤣🤣🤣

 

[thesauce]

So, 3 x 6 Gy with a single pa field for a bone met in the lumbar spine is SBRT? 🤣🤣🤣

I‘ve never done that one. For palliation, I would generally do 8 Gy/1 fx, 20 Gy/5 fx, or 30 Gy/10 fx.

I probably wouldn’t use 18 Gy/3 fx unless in previously-irradiated field where I really had to pull my punches in which case I wouldn’t use a single PA field and I probably would call it SBRT.

 

[TheWallnerus]

Medicare Advantage is supposed to cover everything Medicare does at a minumum. They still deny some of those things but I believe it’s either illegal or violates their contract with Medicare (or both).

Wrong

“What Medicare covers” is INCREDIBLY subjective because just because they pay doesn’t mean it’s covered (and medically necessary, or “doesn’t exceed the medical need,” or not recoverable in a RAC audit, etc).

EDIT: E.g., not a single Medicare SBRT LCD/LCA lists breast cancer as a coverable diagnosis or coverable on med nec grounds. AND even if it were a covered ICD-10 in an LCA, that doesn't mean it's free rein for "adjuvant SBRT" for Stage I breast.

 

[TheWallnerus]

This is kind of germane to this discussion but in some locales the proton centers, when they do 5 fraction high dose, bill out as SBRT because they can get a better Medicare payment rate for the SBRT fraction than a proton fraction.

But this is acceptable because Medicare has said it's ok:

 

[dieABRdie]

I've found the setups to be so reproducible we don't go to the machine to check daily, unless the therapists have a concern. I'd gladly go check if they paid us for it.

I'm going to add my 2 cents in support. But sadly... I think the cats out the bag on this one. ASTRO hasn't supported the community before, I don't expect them to now.

 

[TheWallnerus]

While I agree and have seen it billed this way, the sheer increase in SBRT volume from Brest alone may trigger massive cuts in reimbursement as a result because of increased utilization.

No good deed will ever go unpunished for us

 

[radiation123]

While I agree and have seen it billed this way, the sheer increase in SBRT volume from Brest alone may trigger massive cuts in reimbursement as a result because of increased utilization.

SBRT reimburses less than conventionally fractionated breast irradiation and is almost equivalent to a 15 fraction IMRT breast plan.

This is a defeatist mindset, by this logic we should never advocate for higher reimbursement. Med onc/drug companies would never think this way, and this is one of the reasons they do so well.

If we/ASTRO do not advocate for ourselves, then reimbursement will continue to fall.

 

[Fpg1245]

SBRT reimburses less than conventionally fractionated breast irradiation and is almost equivalent to a 15 fraction IMRT breast plan.

This is a defeatist mindset, by this logic we should never advocate for higher reimbursement. Med onc/drug companies would never think this way, and this is one of the reasons they do so well.

If we/ASTRO do not advocate for ourselves, then reimbursement will continue to fall.

Never should have gone down this path…

 

[radiation123]

In my part of the country insurance flatly refused to consider 5 fx apbi per Florence to be SBRT. While it's incredibly frustrating, the only thing I could agree with them on is that SBRT doesn't usually have a CTV or large CTV/PTV expansions. Florence does 1.5 + 1cm CTV and PTV.

If we were doing pre-op treatment with same fractionation to GTV + 5 or something I think we'd have a better case.

I would argue the reason that insurance is able to deny this is because ASTRO/radiation oncologists have not formally called it SBRT. The point of this thread is that we should lobby ASTRO to call it SBRT so we can start the process of it getting reliably reimburesed as SBRT.


I disagree with your statement "SBRT doesn't usually have a CTV or large CTV/PTV expansions." SBRT often has CTV. Prostate SBRT has a CT. Spine SBRT has a CTV and depending on the size/location of the lesion/GTV the CTV expansion in certain directions can be equal to or greater than a 1.5 cm expansion on the GTV.


If the PTV expansion is a problem for you then just change your CTV expansion to 2 cm and your PTV expansion to 5 mm. In the guidelines we are discussing they already state for 5 fractions breast " PTV: 1 cm margin around CTV. For patients undergoing daily imaging, tighter margins may be considered depending on accuracy of patient setup"

 

[deleted1111261]

Many do submit it as such and sounds like it is getting covered

 

[radiation123]

Agree. You’re lacking the heterogeneity and tight margins that every other sbrt paradigm employs. If you’re concerned about the financials of partial breast, do IMPORT LOW. it’s the most evidenced based PBI regimen

I don’t think that heterogeneity is the defining feature of SBRT. AAPM task group 101 defines it "as the delivery of large doses in a few fractions, which results in a high biological effective dose BED". They also give a chart with characteristics of SBRT which is in my second post. If given with appropriate imaging, machine QA and physician/physics supervision, it would also meet the characteristics of SBRT in that table.


If you are concerned about the PTV margin, then just change your CTV expansion to 2 cm and your PTV expansion to 5 mm. In the guidelines we are discussing they already state for 5 fractions breast " PTV: 1 cm margin around CTV. For patients undergoing daily imaging, tighter margins may be considered depending on accuracy of patient setup."

IMPORT LOW is a good regimen and I have used it in the past. It does require the patient to come to 10 more visits which is suboptimal. Also given the results of FAST-FORWARD, if you use doses on the lower end of what is acceptable for 5 fraction breast it would be very hard to argue that it has clinically significant inferior cosmetic or tumor control compared to IMPORT LOW.

 

[radiation123]

Private insurance will never accept this.

You can go ahead and bill this out as SBRT on Medicare patients now however. OTOH todays Medicare patient is tomorrows Medicare Advantage patient. And then we are back in same private insurance boat.

The point of the thread is that if enough people comment on the guidelines they may add it as an accepted technique which would be a good first step in it getting accepted by insurance.

 

[radiation123]

I've found the setups to be so reproducible we don't go to the machine to check daily, unless the therapists have a concern. I'd gladly go check if they paid us for it.

I'm going to add my 2 cents in support. But sadly... I think the cats out the bag on this one. ASTRO hasn't supported the community before, I don't expect them to now.

Thanks for you support. If you havent already please send a comment to ASTRO asking them to change their guidlines. The comments period ends July 5th. Link is below

Public comment - American Society for Radiation Oncology (ASTRO) - American Society for Radiation Oncology (ASTRO)

ASTRO posts draft clinical practice guidelines and practice documents for public comment before they are finalized and sent to ASTRO's Board of Directors for approval.

www.astro.org

 

[thesauce]

Wrong

“What Medicare covers” is INCREDIBLY subjective because just because they pay doesn’t mean it’s covered (and medically necessary, or “doesn’t exceed the medical need,” or not recoverable in a RAC audit, etc).

EDIT: E.g., not a single Medicare SBRT lists breast cancer as a coverable diagnosis or coverable on med nec grounds. AND even if it were a covered ICD-10 in an LCA, that doesn't mean it's free rein for "adjuvant SBRT" for Stage I breast.

View attachment 373804

I don’t fully disagree with you, but we’ve been debating the definition of SBRT for pages on this thread and others…it’s difficult to define. I remember it being that way when we did our case logs in residency and we were trying to decide what exactly qualified as an SBRT case. 25 Gy in 5 fractions to the spine is universally considered SBRT but a similar dose to the breast, rectum, or anywhere else that often demonstrates even more motion is not? And now it’s ok to bill for breast SBRT with protons but photons are debatable? Because that makes a lot of sense…

I’m sure Medicare Advantage plans have SOME leeway with regard to the treatment modality used but I’ve seen them deny Dupuytren’s treatment (for instance) when it is clearly a covered code under Medicare. No one is billing SBRT for that one.

 

[Reaganite]

EDIT: E.g., not a single Medicare SBRT lists breast cancer as a coverable diagnosis or coverable on med nec grounds. AND even if it were a covered ICD-10 in an LCA, that doesn't mean it's free rein for "adjuvant SBRT" for Stage I breast.


Most relevant post in the thread. Medicare does not pay for sbrt for any primary breast diagnosis. Someone mentioned payors are covering this? I'd like to know which ones because commercial payors are uniformly stricter than Medicare.

 

[TheWallnerus]

I would argue the reason that insurance is able to deny this is because ASTRO/radiation oncologists have not formally called it SBRT. The point of this thread is that we should lobby ASTRO to call it SBRT so we can start the process of it getting reliably reimburesed as SBRT.

I wholeheartedly agree w/ your sentiment that doing high dose per fraction, five fraction breast RT is SBRT.

However, there will need to be a "plausible story" to tell insurance companies about why high dose per fraction, five fraction breast RT is SBRT. And it will need to be medically based (ie, SBRT was proven superior to IMRT in a trial); if it's wonky and jargon-y and couched in the language of billing/coding minutiae, it will not work IMHO. Keep in mind, some payors like United and Evicore are already defining 5 fraction breast as IMRT.

Agree with all your cost neutral arguments vs 3 or more weeks of non-SBRT RT. Yet somehow these arguments don't seem to work w/ payors.

Medicare does not pay for sbrt for any primary breast diagnosis.

Medicare will pay.

But it might be a perilous check they are cutting!

You'd just have to bill it, collect the money, rinse/repeat over and over, and later avoid a whistleblower and/or audit.

 

[radiation123]

I wholeheartedly agree w/ your sentiment that doing high dose per fraction, five fraction breast RT is SBRT.

However, there will need to be a "plausible story" to tell insurance companies about why high dose per fraction, five fraction breast RT is SBRT. And it will need to be medically based (ie, SBRT was proven superior to IMRT in a trial); if it's wonky and jargon-y and couched in the language of billing/coding minutiae, it will not work IMHO. Keep in mind, some payors like United and Evicore are already defining 5 fraction breast as IMRT.

Agree with all your cost neutral arguments vs 3 or more weeks of non-SBRT RT. Yet somehow these arguments don't seem to work w/ payors.

Medicare will pay.

But it might be a perilous check they are cutting!

You'd just have to bill it, collect the money, rinse/repeat over and over, and later avoid a whistleblower and/or audit.

I agree that ASTRO calling 5 fractions breast SBRT would not solve all our insurance problems. However, it would be a good first step. We have to start somewhere. At the very least if a commercial payer has you do a peer to peer you could cite the ASTRO guidelines as a reference.

If you have not already, please send a comment to ASTRO.

 

[Reaganite]

At least in my neck of the woods if you bill with an icdd10 not included in the lcd/lca for the particular modality all your treatment codes are auto denied. They will pay E&M codes, sim charges, clinical treatment planning etc, but all your 77373s will be denied. So maybe the prof codes do get paid but you aren't getting the big money treatments paid.

Medicare will pay treatment codes for any icdo10 listed in the relevant lcd/lca but like you mentioned this doesn't mean you cant get hit with a recoup later on if you cannot justify the treatment.

 

[TheWallnerus]

At least in my neck of the woods if you bill with an icdd10 not included in the lcd/lca for the particular modality all your treatment codes are auto denied. They will pay E&M codes, sim charges, clinical treatment planning etc, but all your 77373s will be denied. So maybe the prof codes do get paid but you aren't getting the big money treatments paid.

Medicare will pay treatment codes for any icdo10 listed in the relevant lcd/lca but like you mentioned this doesn't mean you cant get hit with a recoup later on if you cannot justify the treatment.

Very true

Interestingly I think the SBRT LCD for Florida was very recently retired

 

[thesauce]

However, there will need to be a "plausible story" to tell insurance companies about why high dose per fraction, five fraction breast RT is SBRT. And it will need to be medically based (ie, SBRT was proven superior to IMRT in a trial); if it's wonky and jargon-y and couched in the language of billing/coding minutiae, it will not work IMHO.

This will not be difficult: “our medical literature refers to this as breast SBRT and these exact same doses and planning/treatment delivery techniques are billed as SBRT in other clinical scenarios.”

 

[radiation123]

EDIT: E.g., not a single Medicare SBRT lists breast cancer as a coverable diagnosis or coverable on med nec grounds. AND even if it were a covered ICD-10 in an LCA, that doesn't mean it's free rein for "adjuvant SBRT" for Stage I breast.


Most relevant post in the thread. Medicare does not pay for sbrt for any primary breast diagnosis. Someone mentioned payors are covering this? I'd like to know which ones because commercial payors are uniformly stricter than Medicare.

We can lobby Medicare to make it a coverable diagnosis, however, first we must call it SBRT ourselves. If ASTRO were to call 5 fraction breast radiation that would be a good first step.