Are restrictive coverage policies the greatest challenge facing U.S. radiation oncologists?

By Jessica Adams, CCA, ASTRO Health Policy Analyst

In the 2018 Member Survey, 48 percent of private practice radiation oncologists and 38 percent of academic/university system radiation oncologists said restrictive coverage policies are one of the greatest challenges they faced in their practices. The complaints that ASTRO’s Payer Relations Committee (PRC) has received from members in 2018 indicate that coverage policies and prior authorization are only becoming more challenging, which is why ASTRO devotes significant advocacy efforts in this area.

As part of ASTRO’s Health Policy Council, the PRC actively works to address payer coverage policy issues to ensure appropriate coverage for radiation oncology patients. PRC regularly reviews and comments on Medicare and private payer policies, including educating payers using ASTRO Model Policies, which contain up-to-date coverage recommendations. In recent months, ASTRO’s PRC has addressed:

Rectal spacers: Over the past two years, ASTRO advocated for coverage of rectal spacers as an effective tool for reducing rectal toxicity associated with treatment for prostate cancer. Many private payers and the majority of Medicare Administrative Contractors (MACs) responded positively to our advocacy. National Government Services (NGS) is the only MAC that considers rectal spacer not medically necessary. ASTRO, the American College of Radiology and American Brachytherapy Society have urged NGS to reconsider its position. NGS appears unwilling to change its decision, but we will continue to emphasize how this restriction will negatively impact prostate cancer patients to encourage NGS to reclassify the procedure.
Radiosurgery: ASTRO also engaged with MAC Noridian after they announced plans to crosswalk payment rates for robotic radiosurgery codes G0339 and G0340 to CPT codes 77372 and 77373, citing the G codes deletion in the 2014 Medicare Physician Fee Schedule (MPFS). This proposal would have resulted in a reduction in reimbursement by as much as 60 percent for the G codes. ASTRO, along with other stakeholder groups, petitioned Noridian to reconsider, and, in July, Noridian modified its decision and announced that it would cut rates for the G codes by 20 percent effective July 1, 2018, and postpone any additional reductions indefinitely.
Image-guided radiation therapy (IGRT): Aetna still requires practices to bill CPT code 77387 Image-guided radiation therapy, which is a carrier priced code. In the fall of 2017, PRC wrote Aetna to accept the image guidance codes recognized in the MPFS, including CPT codes 77014, G6001, G6002 and G6017. Aetna has stated that, though it is permissible per CPT to bill these codes, they feel it is more appropriate to bill 77387-26. However, Aetna acknowledges the reimbursement impact and recommends that practices contact them regarding a rate review. ASTRO’s PRC issued steps practices may take to perform a rate review, if appropriate. PRC continues to urge Aetna to update their intensity-modulated therapy radiation (IMRT) policy to align with the ASTRO model policy and to recognize 77014, G6001, G6002 and G6017.  
Prior Authorization: In May, Radiation Oncology Benefit Manager eviCore released updated 2018 Radiation Therapy Clinical Guidelines. EviCore, utilized by many private payers to perform prior authorization and other duties, considered post-operative stereotactic radiosurgery (SRS) not medically necessary. ASTRO advocated that post-operative SRS is superior to observation alone in terms of local control, and superior to whole brain radiation therapy (WBRT) in terms of preservation of cognitive function. Based on ASTRO’s comments, eviCore modified their coverage policy on the use of for post-operative SRS brain metastases, effective August 1, 2018.
ASTRO encourage members to reach out to PRC when experiencing struggles with payers. For more information regarding ASTRO PRC efforts to address payer issues, including copies of letters and payer guidance, see the ASTRO website. Attend the 2019 Radiation Oncology Coding and Reimbursement Update during ASTRO’s Annual Meeting for more in-depth information on payer coverage issues that impact the field of radiation oncology. ASTRO is also hosting its third Coding and Coverage Seminar on December 7-8. This is another great opportunity to learn the ins and outs of radiation oncology coding and coverage. Registration is open and filling up fast!
Posted: September 11, 2018 | 0 comments

ASTRO’s palliative thoracic guideline update recommends the use of concurrent chemotherapy for some patients

By Ehsan Balagamwala, MD, and Benjamin J. Moeller, MD, PhD

In 2011, ASTRO published a guideline on palliative thoracic radiation therapy (RT) which covered dose and fractionation for external beam radiation therapy (EBRT) and the roles of endobronchial brachytherapy (EBB) and chemotherapy given concurrently with EBRT. Pertinent to the update discussed below, the original guideline task force concluded that there was no role for concurrent chemotherapy with palliative EBRT for lung cancer. This recommendation was based on a single randomized control trial (RCT) by Ball et al., which showed improved overall response rates with concurrent chemotherapy. However, it also reported increased esophageal toxicity, as well as no improvement in overall survival, progression-free survival or symptom palliation.
ASTRO’s current guideline methodology includes periodic review of published guidelines for consideration of revision based on new data. A task force was convened in 2016 to review the palliative thoracic guideline briefly summarized above and they issued the results of this review in a guideline update published in the July-August issue of Practical Radiation Oncology. An updated literature review was performed for all three original key questions. The task force felt that the original statements on the questions of EBRT dose and fractionation, as well as those on EBB should be left intact. However, new data on the utilization of concurrent chemotherapy with palliative EBRT prompted the task force to recommend revising its guidance on this question.
For patients with stage IV lung cancer, the recommendation against concurrent chemoradiation was unchanged. However, recommendations on the palliative management of incurable stage III non-small cell lung cancer (NSCLC) were revised based on two additional RCTs published after the original guideline was released: one by Nawrocki et al., and another by Strom et al. Both of these trials had two strengths lacking in the study by Ball and colleagues: First, protocol-specified definitions of incurable stage III NSCLC (Ball et al., did not have well-defined eligibility criteria) and second, utilization of platinum-containing multiagent chemotherapy, which has been shown to have the most activity in NSCLC (Ball et al., utilized single agent fluorouracil).
With the addition of chemotherapy, both Nawrocki et al., and Strom et al., showed improvement in overall survival, albeit with increased risk of grade 3-4 toxicity (neutropenia and esophagitis) with concurrent chemoradiation. Based on these new trials, the task force recommended that a subset of patients (chemotherapy candidates, Eastern Cooperative Oncology Group performance status 0-2, and life expectancy ≥ 3 months), who are not candidates for either definitive concurrent chemoradiation or sequential chemoradiation, would benefit from concurrent chemotherapy with moderately hypofractionated RT.

In the months since this guideline was released, there has been engaging discussion via social media and scientific meetings, largely aimed at clarifying two important points:
  • How should the guideline reader define “incurable” stage III NSCLC?
  • How can the guideline reader be reassured as to the safety of concurrent chemotherapy with palliative thoracic EBRT?
Though data demonstrate that many patients with stage III NSCLC are managed with palliative intent, no validated criteria have been defined for which patients are best treated this way, which complicates clinical research done in this space. The two studies primarily informing this update used largely non-overlapping criteria for defining incurable stage III NSCLC and, therefore, could not be used as a basis for this definition. Further, developing a definition of incurability was beyond the scope of this guideline update. Therefore, we chose to leave it to the discretion of the treating physician to determine candidacy for curative therapy in this context. The recommendation to utilize concurrent chemotherapy would apply only to those stage III NSCLC patients who they have deemed incurable in their individual practices (i.e., those patients that are treated with palliative intent and will receive only palliative RT and/or chemotherapy as a part of their treatment course). 
When recommending escalating treatment intensity in the palliative care arena, treatment toxicity is an important consideration. Specific to the question of concurrent palliative thoracic chemoradiation is the risk for esophagitis. Ball et al., reported grade 3 esophagitis in 3 percent for RT alone versus 12 percent for chemoradiation (p<0.01). Nawrocki et al., did not find a statistically significant difference in risk for grade 3 esophagitis (0 percent RT versus 2 percent chemoradiation) but did find increased risk for grade 3 or 4 neutropenia with concurrent chemotherapy. Finally, Strom et al., found increased risk of grade 3 esophagitis with chemoradiation (1.5 percent versus 30 percent, p<0.01). Overall, the task force members concluded that the modest increase in the risk of acute esophagitis was outweighed by significant improvements in not only response rates and survival but also symptom control and quality of life with the addition of concurrent chemotherapy to palliative thoracic EBRT.
Finally, we applaud the investigators involved in all the referenced trials. Randomized clinical studies focused on palliative radiotherapy are relatively uncommon, partly due to the difficulties involved in conducting them. Given the prevalence of palliative care in our field and its understood value for our patients, we appreciate these efforts and encourage more investigation to further clarify these important issues.
Dr. Balagamwala served as the resident representative on the task force for this guideline; he recently completed his residency at the Cleveland Clinic, where he is now an attending physician in the Department of Radiation Oncology. Dr. Moeller chaired the update to the ASTRO guideline on palliative thoracic radiation therapy and is a member of the ASTRO Guidelines Subcommittee. He works at Southeast Radiation Oncology Group in Charlotte, North Carolina.
Posted: September 5, 2018 | 0 comments

Help us make ASTROnews better—take the readership survey online

By Najeeb Mohideen, MD, FASTRO

It’s been two years since I assumed the mantle of Senior Editor of ASTROnews. In that time, we’ve welcomed a new managing editor and two new editorial board members, brought the issue back into print from a year of being online-only, changed up the back departments and tackled a litany of topics of interest to our readers: from emerging immunotherapy research to the diversity of the radiation oncology workforce.

Now it’s time for us to assess our progress; to take stock of where the magazine is now and where it should be headed. Like we do when we’re treating patients in the clinic, we have to look at our results to see if we’re moving in the right direction: Is the plan working? Have we gone off course? Could it be refined?

Just as we strive for the optimal treatment plan for our patients, the ASTROnews editorial board and I strive to make your member magazine as relevant and useful as possible. We are collecting information to see what’s working in ASTROnews and what could use some improvement.

We want to know if you read ASTROnews—and how you prefer to read it: online, in print, a mixture of both? Would you read online-only content on our website in between issues? Do you find the issue themes and related stories applicable to your practice? What themes should we address in future issues?

Please take a moment—it takes less than 10 minutes—to fill out the brief survey with your thoughts about ASTROnews. Let me thank you in advance for taking the time to share your feedback with us so that we can, in turn, focus in on the topics of greatest interest to our readers.
Posted: August 29, 2018 | 0 comments

Practice-changing research to be presented at the 2018 ASTRO Annual Meeting

By Lisa A. Kachnic, MD, FASTRO, Chair, Annual Meeting Scientific Committee

A strong selection of late-breaking abstracts was submitted for this year’s ASTRO Annual Meeting. A total of 61 abstracts were received within the late-breaking abstracts window between July 19 and August 1, and 10 of them have been selected for oral presentation.

An important, practice-changing study, NRG-RTOG 1016: A Phase III Trial Comparing Radiation/Cetuximab to Radiation/Cisplatin in HPV-related Cancer of the Oropharynx, has been added to the Plenary Session. An interim analysis of data from a randomized clinical trial of patients with human papillomavirus (HPV)-positive oropharyngeal cancer found that treatment with radiation therapy and cetuximab is associated with worse overall and progression-free survival compared to the current standard treatment with radiation and cisplatin. Full study details will be presented on Monday, October 22 in San Antonio. A second late-breaking abstract has also been added to the Plenary Session, Short Term Androgen Deprivation Therapy Without or With Pelvic Lymph Node Treatment Added to Prostate Bed Only Salvage Radiotherapy: The NRG Oncology/RTOG 0534 SPPORT Trial.

Three late-breaking abstracts have been chosen for the Clinical Trials Session. These include:

  • A Randomized Trial Evaluating Radiation following Surgical Excision for “Good Risk” DCIS: 12-year Report from NRG/RTOG 9804.
  • FAST Phase III RCT of Radiotherapy Hypofractionation for Treatment of Early Breast Cancer: 10-year Results.
  • Local Consolidative Therapy Improves Overall Survival Compared to Maintenance Therapy/Observation in Oligometastatic Non-Small Cell Lung cancer: Final Results of a Multicenter, Randomized Controlled Phase II Trial.


The Late-breaking Abstracts Special Session will feature five more late-breaking abstracts:

  • Preservation of Neurocognitive Function with Conformal Avoidance of the Hippocampus During Whole-brain Radiotherapy for Brain Metastases: Preliminary Results of Phase III Trial NRG Oncology CC001.
  • Overall survival with Durvalumab versus Placebo after Chemoradiotherapy in Stage III NSCLC: Updated Results from PACIFIC.
  • Plasma Circulating Tumor HPV DNA for the Surveillance of Cancer Recurrence in HPF-associated Oropharyngeal Cancer.
  • An International Randomized Phase III Trial Evaluating Efficacy and Safety in First-in-Class NBTXR3 Hafnium Oxide Nanoparticles Activated by Preoperative Radiotherapy in Locally-advanced Soft Tissue Sarcoma.
  • Preoperative Chemoradiotherapy Potentially Improves Outcome for (Borderline) Resectable Pancreatic Cancer: Preliminary Results of the Dutch Randomized Phase III Preopanc Trial.

Abstracts submitted as late-breaking abstracts must meet specific criteria. Research is limited to highly significant and timely findings in clinical oncology, radiobiology or medical physics that were not available prior to the February 14 abstract submission deadline. Only abstracts deemed to be of high scientific priority are considered for presentation in the Plenary, Clinical Trials or late-breaking abstract sessions, and so standards for accepting late-breaking abstracts for presentation are much higher than those for abstracts accepted for the general scientific sessions.

A special panel of peer reviewers are responsible for selecting abstracts to be presented. All abstracts are scored, and then the Annual Meeting Steering Committee, comprised of the Chair and Vice-chair of the Annual Meeting Scientific and Education Committees, along with the current ASTRO President, President-elect, Education Council Representative, Best of ASTRO Chair and two statisticians discuss which abstracts fit best in these high-level sessions.

View all the scientific and education sessions to be presented at the 60th ASTRO Annual Meeting, taking place October 21-24, 2018, at the Henry B. Gonzalez Convention Center in San Antonio on the Conference Planner. Register for the meeting by September 13 for advance rates.

Posted: August 22, 2018 | 0 comments

Mips scores have radiation oncology asking, that's it?

By Randi Kudner, ASTRO Senior Quality Improvement Manager

Radiation oncologists and other physicians are struggling to maximize return on investment under the new Merit-based Incentive Program Payment System (MIPS), compounding questions about the new program’s burden and value.
The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) established the Quality Payment Program (QPP) to transition Medicare payment away from fee-for-service to pay-for-performance. Participation in the QPP is through one of two pathways. The Advanced Alternative Payment Model (APM) is one option; however, only radiation oncologists in a multidisciplinary practice involved in the Oncology Care Model currently have this option. A radiation oncology APM is currently in development.

The Merit-based Incentive Payment System (MIPS) is the other option, and it is how most radiation oncologists currently report. MIPS combines and replaces Physician Quality Reporting System (PQRS), Value-based Payment Modifier (VM) and Medicare EHR Incentive (Meaningful Use) programs into one comprehensive program.

The Center for Medicare and Medicaid Services (CMS) recently released feedback data for the 2017 MIPS performance year. Included in the feedback report is the:
  • 2017 final score
  • 2019 MIPS payment adjustment
  • Final performance category scores and weights

As we work to influence the 2019 QPP proposed rule, we are also interested in gathering performance data from our members so that we may advocate effectively on theirn behalf. What was the participation rate? What were the scores? How did our members perform? 
ASTRO requested feedback data from some groups and has some initial data, but we need more responses to advocate for program improvements. The 2017 program included up to a positive or negative 4 percent payment adjustment for 2019, and many ASTRO members that were initially polled scored a perfect 100.  However, when all calculations were averaged, this only equates to a 2.02 percent positive payment adjustment in 2019. 
There was little surprise that the positive payment adjustments were lower than the 4 percent ceiling, considering the budget neutral mandate combined with the "Pick Your Pace" option introduced to ease practices into the new program. Yet the fact that the positive adjustment was so low—about half of the maximum—means that some program rules should be reviewed. Realistically, if the program is to succeed, there should be a meaningful financial benefit, alongside the potential quality improvement impact, that offsets the significant cost of participation. Clinicians and groups can access their 2017 MIPS performance feedback on the QPP website using an Enterprise Identity Management (EIDM) account. The CMS Guide to Obtaining an EIDM Account provides instructions on how to create one. If an error was made in the calculation of your 2019 MIPS payment adjustment, you should request a targeted review from CMS via your EIDM account on the QPP website. Targeted reviews can be submitted until October 1, 2018. Circumstances warranting such a request include:
  • Errors or data quality issues on submitted measures and activities; 
  • Physician eligibility questions that could, for instance, be related to CMS’s low-volume threshold and that would preclude a payment adjustment; 
  • An erroneous exclusion from the alternative payment model participation list; or
  • Failure to be automatically reweighted due to eligibility provided by CMS’s 2017 extreme and uncontrollable circumstances policy.
Understanding participation, performance and the cost/benefit ratio will inform ASTRO’s recommendations to CMS on future iterations of the program. Please fill out this short survey to help ASTRO provide suggestions to CMS about how to refine this program moving forward.
Posted: August 8, 2018 | 0 comments

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