Reflexion gets new reimbursement codes

[Gfunk6]

From their official communication:

NEWS ALERT

CMS EXPANDS REIMBURSEMENT FOR SCINTIX THERAPY We're excited to share that the Centers for Medicare and Medicaid (CMS) expanded the reimbursement for SCINTIX® therapy on multiple fronts. Here are the highlights effective as of January 1, 2025: New G-codes will replace C-codes to allow for payment in both hospitals and freestanding centers. And, SCINTIX therapy is paid at nearly twice the rate of SBRT which further supports new technology adoption. In addition to granting G-codes for SCINTIX therapy, CMS also created a professional component for SCINTIX modeling. This applies to both hospitals and freestanding centers and recognizes physician resources during this key step in the workflow, which ensures the tumor has the required avidity to enable SCINTIX therapy. CMS will now pay separately for diagnostic radiopharmaceuticals with a per diem cost more than $630. This represents a positive step as more expensive radiopharmaceuticals, such as PSMA and FAP are developed for future use in directing SCINTIX therapy. This exciting news further supports the adoption of SCINTIX therapy - a breakthrough technology that leverages radiopharmaceuticals to deliver a tracked radiation dose.

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At present, I don't think United/Aetna/Blues/Evil-Corp will touch treating 20 mets simultaneously with a 10 foot pole. However, if you need help targeting limited bone mets from cancer and you are not adverse to injecting a patient multiple times with radioactive tracer, then a Reflexion may be for you.

Besides, why deal with archaic technology like CBCT localization when you get can paid more by doing something else?

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[BobbyHeenan]

We don't have unique codes for adaptive or MRI linacs but this PET thing that is rendered obsolete by a decent image fusion gets codes in no time.

This has got to be because they went down some pharma pathway or something. Makes no sense to me.

 

[Gfunk6]

We don't have unique codes for adaptive or MRI linacs but this PET thing that is rendered obsolete by a decent image fusion gets codes in no time.

This has got to be because they went down some pharma pathway or something. Makes no sense to me.

As I understand it, this decision was preceded by CMS giving them a "novel" technology status which was sought but not achieved by MR linac manufacturers.

 

[BobbyHeenan]

As I understand it, this decision was preceded by CMS giving them a "novel" technology status which was sought but not achieved by MR linac manufacturers.

Would love to know who greased the wheels on that one....probably pharma money from pet/radiopharm producers.

 

[medgator]

Would love to know who greased the wheels on that one....probably pharma money from pet/radiopharm producers.

You don't make as much money on the printer/linac, you make money selling the ink/pharma/radiopharm refills and the maintenance contracts

 

[Gfunk6]

You don't make as much money on the printer/linac, you make money selling the ink/pharma/radiopharm refills and the maintenance contracts

 

[thesauce]

This is so dumb. No self-respecting RadOnc would push this. It is entirely based on trying to fool patients.

 

[StIGMA]

This is so dumb. No self-respecting RadOnc would push this. It is entirely based on trying to fool patients.

But it fits perfectly in a shipping container and will solve access issues in Africa! (this was part of their old pitch for the newbies)

 

[NotMattSpraker]

Would love to know who greased the wheels on that one....probably pharma money from pet/radiopharm producers.

We recorded a podcast with their CTO and CMO, 6/24/24. I want to say right at the top I am not pushing this machine. In fact, when it came up at work, I argued that it doesn't make a lot of sense for our practice today. I would worry that it would be installed and then I would be pressured to put people on it when its not clear to me why it helps my patients over my current available technology. Remember that right now it is only approved to treat bone and lung mets.

A lot of the motivation for putting this episode out is that the CMO is a radiation oncologist and in my opinion he does an excellent job as a CMO... so someone paid to push a product. This field needs a lot more examples of people that develop and bring technology to market, and then speak about them publicly in an honest way. Its not for me, but everyone says they want more industry engagement and funding. I can think of several Rad Onc "career paths" that many follow that are less useful for our field 🙂

I think he is a good role model given the current culture of our field and US healthcare tech development environment. There are a million things I dont like about aspects of our field, but being angry at them doesnt change reality.

If people listen, I always love feedback.

They talk a bit about how they were able to get a code, and I've heard rumors about why adaptive wasn't able to get a code. This is mostly politics, unfortunately has very little to do with the "scientific value" of the devices.

Overall I found their talking points refreshing compared to proton folks or adaptive folks. That said, the argument for the machine today is pretty weak if you are an expert radiation oncologist. In my opinion, your role of as the local expert is to stop your practice/hospital from buying it if you do not think it helps your patients.

The argument is really that the machine is a future play.

It becomes a lot more compelling in a world where there are radiotracers for a lot of different types of cancers. Also, if metabolic response adapted therapy becomes more ubiquitous in clinic. It is not crazy, but it is way early. There are a few examples of metabolic response adapted therapy today and clearly radiopharmceuticals are very hot right now (ha).

A lot of people are acting like radiopharm will be the savior of our field. They made a machine that leverages that excitement.

Its hard to argue that it doesnt deserve a different CPT code given how the CPT coding system operates. It is an entirely different process than our current SBRT planning process. I am not arguing it is better for the patient, just saying that it is different how 3D is different than IMRT or SBRT.

I thought they mentioned that private insurances are paying it out, but I am not sure.

Again, I am not arguing this is the right thing. I just think it has more potential than PET fusion and could be a paradigm that looks pretty different in 10 years.

Or not. Time will tell.

But Im just not sure how we move forward if we complain about the lack of investment in tech development in this field but then also say every new device is stupid.

 

[BobbyHeenan]

We recorded a podcast with their CTO and CMO, 6/24/24. I want to say right at the top I am not pushing this machine. In fact, when it came up at work, I argued that it doesn't make a lot of sense for our practice today. I would worry that it would be installed and then I would be pressured to put people on it when its not clear to me why it helps my patients over my current available technology. Remember that right now it is only approved to treat bone and lung mets.

A lot of the motivation for putting this episode out is that the CMO is a radiation oncologist and in my opinion he does an excellent job as a CMO... so someone paid to push a product. This field needs a lot more examples of people that develop and bring technology to market, and then speak about them publicly in an honest way. Its not for me, but everyone says they want more industry engagement and funding. I can think of several Rad Onc "career paths" that many follow that are less useful for our field 🙂

I think he is a good role model given the current culture of our field and US healthcare tech development environment. There are a million things I dont like about aspects of our field, but being angry at them doesnt change reality.

If people listen, I always love feedback.

They talk a bit about how they were able to get a code, and I've heard rumors about why adaptive wasn't able to get a code. This is mostly politics, unfortunately has very little to do with the "scientific value" of the devices.

Overall I found their talking points refreshing compared to proton folks or adaptive folks. That said, the argument for the machine today is pretty weak if you are an expert radiation oncologist. In my opinion, your role of as the local expert is to stop your practice/hospital from buying it if you do not think it helps your patients.

The argument is really that the machine is a future play.

It becomes a lot more compelling in a world where there are radiotracers for a lot of different types of cancers. Also, if metabolic response adapted therapy becomes more ubiquitous in clinic. It is not crazy, but it is way early. There are a few examples of metabolic response adapted therapy today and clearly radiopharmceuticals are very hot right now (ha).

A lot of people are acting like radiopharm will be the savior of our field. They made a machine that leverages that excitement.

Its hard to argue that it doesnt deserve a different CPT code given how the CPT coding system operates. It is an entirely different process than our current SBRT planning process. I am not arguing it is better for the patient, just saying that it is different how 3D is different than IMRT or SBRT.

I thought they mentioned that private insurances are paying it out, but I am not sure.

Again, I am not arguing this is the right thing. I just think it has more potential than PET fusion and could be a paradigm that looks pretty different in 10 years.

Or not. Time will tell.

But Im just not sure how we move forward if we complain about the lack of investment in tech development in this field but then also say every new device is stupid.

Good points/perspective.

Part of my frustration is that I've recently taken deep dive into the MRI linacs and adaptive machines, etc... proformas ...etc...and there's just so much uncertainty about who is getting paid in what cases for new adaptive plans. An on-the-table rapid new adaptive plan tech is here and seemingly has just as much "data" as this machine (and certainly more patients being treated in this manner) and yet this PET machine has codes and none in sight for MRI or adaptive planning.

 

[medgator]

yet this PET machine has codes and none in sight for MRI or adaptive planning.

Pharma has better lobbyists

 

[OTN]

Nonsense, just complete nonsense.

No one has been able to explain to me how Reflexion is in any way different (other than throughput) than CT sim ---> fuse with diagnostic PET/CT --> treat with SBRT.

Can anyone do that here? I do know that throughput is improved as mentioned above. Should that in and of itself be enough for a new code?

 

[Palex80]

In fact, when it came up at work, I argued that it doesn't make a lot of sense for our practice today. I would worry that it would be installed and then I would be pressured to put people on it when its not clear to me why it helps my patients over my current available technology.

(for 90% of the protons-treated patients)

 

[Gfunk6]

Nonsense, just complete nonsense.

No one has been able to explain to me how Reflexion is in any way different (other than throughput) than CT sim ---> fuse with diagnostic PET/CT --> treat with SBRT.

Can anyone do that here? I do know that throughput is improved as mentioned above. Should that in and of itself be enough for a new code?

See this thread.

The tl;dr version:

1. Due to extremely rapidly rotating tomo technology, it can treat multiple mets - up to 10-20+ simultaneously.
2. Rather than relying on PET imaging that is days or weeks old for fusion, this technology gets a new PET scan each time immediatley prior to treatment. This allows for "real time" delivery and can pick up new areas of disease that meet thresholds for treatment.

 

[Palex80]

1. Due to extremely rapidly rotating tomo technology, it can treat multiple mets - up to 10-20+ simultaneously.

RADIXACT can do that too, right?

 

[Gfunk6]

RADIXACT can do that too, right?

I'm not a technical expert by any means, but my understanding is the rotational speed of Reflexion far exceeds that of any existing Tomo technologies.

Edit: Found it online. Reflexion X1 spins at 60 RPM and Radixact can spin 1-5 RPM when treating and up to 10 RPM when imaging.

 

[Doctorer]

Nonsense, just complete nonsense.

No one has been able to explain to me how Reflexion is in any way different (other than throughput) than CT sim ---> fuse with diagnostic PET/CT --> treat with SBRT.

Can anyone do that here? I do know that throughput is improved as mentioned above. Should that in and of itself be enough for a new code?

Keep in mind, throughput wise, you're going to be significantly slower with a Reflexion.

ie, patient injection, tracer distribution, patient imaging, review, etc.

Maybe that's why the reimbursement is higher?

 

[BobbyHeenan]

I hate to the be thread hater....but we can barely tell (or can we tell at all?) that ablating 1-3 mets in oligometastatic disease helps.

But the incremental benefit of this machine treating up-to-date 10-20 mets (or finding tiny ones) better/faster than me fusing the pet an da week later treating the 10 mets is worth it?

I'm glad they invented this thing, but it seems like if we had a functional system we would make a few of them and allow them to treat pateints on a trial on it THEN later approve it for commercial use. Instead we're going to get these codes, start rolling them out , then figure out in 10 years after they've printed money that it didn't do any good.

I would love it if some place like MDA or MSK rolled out these experimental machines and started putting randomized patients on them. That is what their PPS exempt status should be doing instead of giving 40 fraction proton prostates.

I guess it's the rules of engagement we have ("don't hate the player hate the game").

*rant over.

 

[ramsesthenice]

Nonsense, just complete nonsense.

No one has been able to explain to me how Reflexion is in any way different (other than throughput) than CT sim ---> fuse with diagnostic PET/CT --> treat with SBRT.

Can anyone do that here? I do know that throughput is improved as mentioned above. Should that in and of itself be enough for a new code?

The idea, and I think idea is the right word here until proven otherwise, is it’s supposed to be PET directed in that the machine is targeting PET tracer for delivery to essentially rapidly adapt the initial plan based on PET signal at the time of treatment. To me, the issue is I don’t think most tracers are good enough to really pull this off for many diseases. We could get there and it would be great if we did. I wouldn’t buy one yet and I agree it’s surprising they got codes…until you understand the convoluted nature of the process.

 

[medgator]

I hate to the be thread hater....but we can barely tell (or can we tell at all?) that ablating 1-3 mets in oligometastatic disease helps.

But the incremental benefit of this machine treating up-to-date 10-20 mets (or finding tiny ones) better/faster than me fusing the pet an da week later treating the 10 mets is worth it?

I'm glad they invented this thing, but it seems like if we had a functional system we would make a few of them and allow them to treat pateints on a trial on it THEN later approve it for commercial use. Instead we're going to get these codes, start rolling them out , then figure out in 10 years after they've printed money that it didn't do any good.

I would love it if some place like MDA or MSK rolled out these experimental machines and started putting randomized patients on them. That is what their PPS exempt status should be doing instead of giving 40 fraction proton prostates.

I guess it's the rules of engagement we have ("don't hate the player hate the game").

*rant over.

Seems fit to repost here

Reflexion gets new reimbursement codes

From their official communication: NEWS ALERT CMS EXPANDS REIMBURSEMENT FOR SCINTIX THERAPY We're excited to share that the Centers for Medicare and Medicaid (CMS) expanded the reimbursement for SCINTIX® therapy on multiple fronts. Here are the highlights effective as of January 1, 2025...

forums.studentdoctor.net

 

[OTN]

See this thread.

The tl;dr version:

1. Due to extremely rapidly rotating tomo technology, it can treat multiple mets - up to 10-20+ simultaneously.
2. Rather than relying on PET imaging that is days or weeks old for fusion, this technology gets a new PET scan each time immediatley prior to treatment. This allows for "real time" delivery and can pick up new areas of disease that meet thresholds for treatment.

1. Throughput only, and I'm not even to start going into the claim that treating 10-20 mets would be beneficial
2. I do not believe that getting a PET 1-2 weeks prior to SBRT makes any clinical difference whatsoever vs. "real time" PET signal. Zero data supports this assumption.

 

[taserlaser]

1. Throughput only, and I'm not even to start going into the claim that treating 10-20 mets would be beneficial
2. I do not believe that getting a PET 1-2 weeks prior to SBRT makes any clinical difference whatsoever vs. "real time" PET signal. Zero data supports this assumption.

Re point 1 - it will be very interesting to see the results of the subsequent studies haha. https://www.sciencedirect.com/science/article/pii/S0360301624025410

 

[ramsesthenice]

1. Throughput only, and I'm not even to start going into the claim that treating 10-20 mets would be beneficial
2. I do not believe that getting a PET 1-2 weeks prior to SBRT makes any clinical difference whatsoever vs. "real time" PET signal. Zero data supports this assumption.

I’ll start by saying conceptually, I agree with you. I think the idea this is going to end up game changing is a bit far fetched and I’m surprised it got codes at this point.

But let’s step back for a second. If we are talking about say prostate cancer and treating 10-20 PYL avid lesions, that’s more or less what we do with Pluvicto (unless you think Pluvicto is delivering enough dose to micromets which in vivo dosimetry studies have yet to demonstrate). For as much as we hale Pluvicto, its benefits are fairly modest. I wouldn’t completely write off the possibility that treating that many Mets with EBRT might offer a PFS or very modest OS benefit. Markedly alter disease course? Absolutely not. Do as much as many targeted small molecule biologics that ASCO strongly promotes with their PR machine? Not impossible.

I can pick apart everything I just said. Even if the specific scenario described panned out, prostate cancer has always been a special case. Is any of this relevant to lung, breast, PDACs etc? Hard to see for me.

I’ll be honest, I have mixed feelings. The scientist in me is trained to be skeptical, demand evidence, and hold ourselves to a very high bar and I can’t give that up. On the other hand, I can’t ignore how other specialty societies keep getting a leg up by aggressively promoting things based more on principle and potential than actual data and keep throwing it at something until it works.

 

[NotMattSpraker]

I’ll be honest, I have mixed feelings. The scientist in me is trained to be skeptical, demand evidence, and hold ourselves to a very high bar and I can’t give that up.

+1

But the Rad Onc in me has learned that this is Rad Onc and I should lower my expectations 🤣

 

[NotMattSpraker]

Good points/perspective.

Part of my frustration is that I've recently taken deep dive into the MRI linacs and adaptive machines, etc... proformas ...etc...and there's just so much uncertainty about who is getting paid in what cases for new adaptive plans. An on-the-table rapid new adaptive plan tech is here and seemingly has just as much "data" as this machine (and certainly more patients being treated in this manner) and yet this PET machine has codes and none in sight for MRI or adaptive planning.

I find it very frustrating and we have only ourselves to blame for all of it.

Reflexion has not even had permission to market the device for 2 full years yet (approved Feb 2023). They claim they will put money in to research and generate data. At one point, Viewray claimed that too and I was excited about that. Now all we have from them are prominent Rad Oncs writing all over Twitter that it is life saving when that has never been shown.

I've basically lost all hope that the US will require good comparative data to approve devices and treatments.

The best thing I think we can do in today's world is teach our trainees not to fall in to this trap.

Totally valid to say the Reflexion makes no sense today for most practices.

 

[IonsAreOurFuture]

I’ll start by saying conceptually, I agree with you. I think the idea this is going to end up game changing is a bit far fetched and I’m surprised it got codes at this point.

But let’s step back for a second. If we are talking about say prostate cancer and treating 10-20 PYL avid lesions, that’s more or less what we do with Pluvicto (unless you think Pluvicto is delivering enough dose to micromets which in vivo dosimetry studies have yet to demonstrate). For as much as we hale Pluvicto, its benefits are fairly modest. I wouldn’t completely write off the possibility that treating that many Mets with EBRT might offer a PFS or very modest OS benefit. Markedly alter disease course? Absolutely not. Do as much as many targeted small molecule biologics that ASCO strongly promotes with their PR machine? Not impossible.

I can pick apart everything I just said. Even if the specific scenario described panned out, prostate cancer has always been a special case. Is any of this relevant to lung, breast, PDACs etc? Hard to see for me.

I’ll be honest, I have mixed feelings. The scientist in me is trained to be skeptical, demand evidence, and hold ourselves to a very high bar and I can’t give that up. On the other hand, I can’t ignore how other specialty societies keep getting a leg up by aggressively promoting things based more on principle and potential than actual data and keep throwing it at something until it works.

I'm glad the Pluvicto trial was positive, any help is welcome for that disease, but I still am skeptical about radiopharmaceuticals as the way forward for most diseases.

Remember Bexxar and Zevalin for lymphoma?

I didn't think so.

They were supposed to allow for radiation to lymphomas too numerous or bulky for EBRT. Turns out, a lot of the radiation labeled antibodies got held up in the liver and spleen and with Bexxar you had to block the thyroid from taking up the radioactive iodine 131. How dumb is that? Instead of ushering in a new era for RT in lymphomas, instead it was the death knell for our role.

Off target binding is still a major issue with all the radio isotopes. Last time I looked at a PSMA scan, the binding was anything but "prostate specific."

Why do I want to risk dry eye and dry mouth when treating prostate cancer? The prostate, bone mets and nodes are nowhere near there.