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 | with 0 comments

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