p2p uptick

[SBRTreble]

Is anyone else noticing a serious increase in the number of denials received for what seems like it should be completely obvious?

I'm regularly having to do p2ps for IMRT/SBRT denial for reirradiation of the spine (i.e. overlapping, abutting or same segment) in a young metastatic breast patient with otherwise limited disease and excellent KPS. It's bananas.

Evicore/Cigna are my most offensive overlords

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[radiaterMike]

I think UHC updated their policies in April. I had a pleasant p2p conversation with an NP from UHC who had never stepped foot in a Rad Onc clinic. I informed her that her decision to deny IGRT, based on zero expertise, would cause irreparable injury by either overdosing the spinal cord or underdoing the patient's cancer. Fortunately whoever reviewed the appeal overturned her denial.

 

[Gfunk6]

Man, it is absolutely crazy. Every time I see a Cigna, United, Aetna or Blue PPO patient I cringe in anticipation of the inevitable peer-to-peer with Boomer Rad Onc practicing in Butthole, USA.

Me: "Well the patient has a solitary recurrence of cancer and we are planning on SBRT."

Them: "I have a piece of paper in front of me that says no, sorry. Feel free to appeal."

Here is a great SFW video by an actual physician that parodies this - he has quite a following on social media

 

[seper]

One way to interpret this, there is a continuing uptick of RadOncs trying to extract every possible charge. Right-sided DIBH, postop SBRT for cord compression, IMRT lumpectomy boost…

 

[Ray D. Ayshun]

My p2p yesterday included "I'm not sure why the nurse didn't just approve this."

 

[radoncle]

Is anyone else noticing a serious increase in the number of denials received for what seems like it should be completely obvious?

I'm regularly having to do p2ps for IMRT/SBRT denial for reirradiation of the spine (i.e. overlapping, abutting or same segment) in a young metastatic breast patient with otherwise limited disease and excellent KPS. It's bananas.

Evicore/Cigna are my most offensive overlords

Yes. And there’s a huge delay to get p2p calls scheduled. I feel like they intentionally delay care to force you into just selecting inferior, less expensive treatments. I’ve heard so many “we can approve 3D now or deny your request” for cases which IMRT is clearly SOC.

 

[DrZap]

Is anyone else noticing a serious increase in the number of denials received for what seems like it should be completely obvious?

I'm regularly having to do p2ps for IMRT/SBRT denial for reirradiation of the spine (i.e. overlapping, abutting or same segment) in a young metastatic breast patient with otherwise limited disease and excellent KPS. It's bananas.

Evicore/Cigna are my most offensive overlords

I’ve noticed a lot going to peer to peer without the insurance doctor even reviewing the records
Now we confirm all records received and reviewed before I get on the phone

 

[Fpg1245]

Yeah the usually come in waves. They hit hard for a few months and then back off. Maybe new fiscal quarter or something

 

[thesauce]

Definitely seen an uptick and the reviews are very low quality. Nit-picking to the extreme.

 

[SBRTreble]

Man, it is absolutely crazy. Every time I see a Cigna, United, Aetna or Blue PPO patient I cringe in anticipation of the inevitable peer-to-peer with Boomer Rad Onc practicing in Butthole, USA.

Me: "Well the patient has a solitary recurrence of cancer and we are planning on SBRT."

Them: "I have a piece of paper in front of me that says no, sorry. Feel free to appeal."

Here is a great SFW video by an actual physician that parodies this - he has quite a following on social media

Love that dude! This clip is fantastic. Would love to see some discussion at ASTRO, not sure what action can be taken collectively, but I'm all in whatever that may be.

One way to interpret this, there is a continuing uptick of RadOncs trying to extract every possible charge. Right-sided DIBH, postop SBRT for cord compression, IMRT lumpectomy boost…

Fair, I am sure there are times where it's necessary. However there appears to be no nuance and little rationale in most cases I've experienced. Not to derail the conversation, but there is some recent phase 2 data for sep surgery + SBRT for MESCC. Impressive downgrading of Bilsky score, if interested: https://www.redjournal.org/article/S0360-3016(21)02560-8/pdf. PMID 34715257

Yes. And there’s a huge delay to get p2p calls scheduled. I feel like they intentionally delay care to force you into just selecting inferior, less expensive treatments. I’ve heard so many “we can approve 3D now or deny your request” for cases which IMRT is clearly SOC.

Definitely having this happen. I've been given a very narrow window to call, or if I'm able to create a break in clinic to receive their call, I've been left hanging multiple times.

 

[thesauce]

Fair, I am sure there are times where it's necessary. However there appears to be no nuance and little rationale in most cases I've experienced. Not to derail the conversation, but there is some recent phase 2 data for sep surgery + SBRT for MESCC. Impressive downgrading of Bilsky score, if interested: https://www.redjournal.org/article/S0360-3016(21)02560-8/pdf. PMID 34715257

I saw this. SBRT for spine is better or at worst neutral. Whether insurance will pay for it is a completely different matter.

 

[medgator]

Definitely having this happen. I've been given a very narrow window to call, or if I'm able to create a break in clinic to receive their call, I've been left hanging multiple times.

Some payors are taking 7-14 business days to do prior auth review/p2p, unless you request stat but in those cases they are changing it on the backend to routine so they don't look bad in front of CMS eyes.

Illegal imo and they should be sued for that.

Also companies that use AIM are awful as aim makes you call them for the p2p and they don't always have a doc available

 

[seper]

I saw this. SBRT for spine is better or at worst neutral. Whether insurance will pay for it is a completely different matter.

SBRT in postop spine can easily lead to more failures compared to 30 / 10 fx:

1. Delays for planning, repeat MR leading to tumor regrowth.
2. Marginal miss due to tight margins, inexperienced contouring.

Terrible idea

 

[thesauce]

SBRT in postop spine can easily lead to more failures compared to 30 / 10 fx:

1. Delays for planning, repeat MR leading to tumor regrowth.
2. Marginal miss due to tight margins, inexperienced contouring.

Terrible idea

Assuming none of those are the case for a particular patient then it’s better: higher doses/better LC and fewer visits.

 

[medgator]

SBRT in postop spine can easily lead to more failures compared to 30 / 10 fx:

1. Delays for planning, repeat MR leading to tumor regrowth.
2. Marginal miss due to tight margins, inexperienced contouring.

Terrible idea

You on the other end of my p2p calls, bro?

 

[Wildcat321]

SBRT in postop spine can easily lead to more failures compared to 30 / 10 fx:

1. Delays for planning, repeat MR leading to tumor regrowth.
2. Marginal miss due to tight margins, inexperienced contouring.

Terrible idea

Is not adding a level above and below for spine cases a terrible idea as well?

 

[seper]

Assuming none of those are the case for a particular patient then it’s better: higher doses/better LC and fewer visits.

8 Gy x 3 SBRT is biologically equivalent to roughly 40 Gy. You will not be making the plan hot either due to the spinal cord in your PTV. Unlikely to improve in-field control compared to 30 Gy / 10

 

[seper]

Is not adding a level above and below for spine cases a terrible idea as well?

For postop cases, yes I always draw generously to include the surgically violated spine area. You do not?

 

[thesauce]

8 Gy x 3 SBRT is biologically equivalent to roughly 40 Gy. You will not be making the plan hot either due to the spinal cord in your PTV. Unlikely to improve in-field control compared to 30 Gy / 10

You’re saying 40 Gy is not better than 30 Gy in terms of local control? You HAVE to be from Evilcore.

 

[seper]

You’re saying 40 Gy is not better than 30 Gy in terms of local control? You HAVE to be from Evilcore.

33 Gy vs 40 BED, strictly speaking. And no god forbid I do not work for Evicore

 

[SBRTreble]

SBRT in postop spine can easily lead to more failures compared to 30 / 10 fx:

1. Delays for planning, repeat MR leading to tumor regrowth.
2. Marginal miss due to tight margins, inexperienced contouring.

Terrible idea

I do worry about insufficient BED based on radbio principles, i.e. less well perfused/oxygenated postop environment. I concede your point that the most likely area for recurrence is in the epidural space and then you're in a pickle. One strategy which has been published is dose painting with IMRT to a lower dose volume, covering all vertebral elements and the thecal sac. I'm sure that Evicore/UHC will be more than thrilled with that approach as well

 

[RadOncDoc21]

I do worry about insufficient BED based on radbio principles, i.e. less well perfused/oxygenated postop environment. I concede your point that the most likely area for recurrence is in the epidural space and then you're in a pickle. One strategy which has been published is dose painting with IMRT to a lower dose volume, covering all vertebral elements and the thecal sac. I'm sure that Evicore/UHC will be more than thrilled with that approach as well

I’ve done this in my own practice… makes me feel better and makes more sense to me then to just leave the areas uncovered when historically we would treat the entire area with no risk of complications. It’s always harder to go back.

 

[Mandelin Rain]

Me: "Well the patient has a solitary recurrence of cancer and we are planning on SBRT."

Them: "I have a piece of paper in front of me that says no, sorry. Feel free to appeal."

Just had this one.

It also included the super pleasant, "I agree with you 100% and would do the same for my patient. But all I can do is give you a fax number for an appeal."

Good use of everyone's time. imo

 

[seper]

Just had this one.

It also included the super pleasant, "I agree with you 100% and would do the same for my patient. But all I can do is give you a fax number for an appeal."

Good use of everyone's time. imo

Guessing your peer was trying to say: "Dr. Rain, I'm actually post-EBM too. I've been working hard trying to put meat on the machine for many years, until getting pushed out by hungrier new grads with 300K in med school debt. Have a good weekend, sir"

 

[deleted1111261]

The companies arguing about giving more non at risk tissue radiation is baffling. Less is less, and that’s good medicine. Sbrt is not special. It just photons arranged differently. It’s not my fault that they get billed differently. If it paid the same, I’d do the most conformal thing on every patient.

 

[DoctwoB]

Yes. And there’s a huge delay to get p2p calls scheduled. I feel like they intentionally delay care to force you into just selecting inferior, less expensive treatments. I’ve heard so many “we can approve 3D now or deny your request” for cases which IMRT is clearly SOC.

This is clearly the case. They use the peer 2 peer ( and your value of time) to save money but using it as a screening tool. If they make you jump through hoops constantly you will only do it in the cases where it is worth fighting for and let the other ones slide, thereby saving them money.

 

[radiaterMike]

The companies arguing about giving more non at risk tissue radiation is baffling. Less is less, and that’s good medicine. Sbrt is not special. It just photons arranged differently. It’s not my fault that they get billed differently. If it paid the same, I’d do the most conformal thing on every patient.

I agree though arguably this is a slippery slope. Should protons be covered for everything ? If so - at a higher reimbursement ? The protons plan always look better. They might not be in actuality of course.

 

[deleted1111261]

I agree though arguably this is a slippery slope. Should protons be covered for everything ? If so - at a higher reimbursement ? The protons plan always look better. They might not be in actuality of course.

That’s fair, but they can be quite toxic (based on studies) so I think it’s different than photons.

I guess I put photons in one basket

 

[Doctorer]

I agree though arguably this is a slippery slope. Should protons be covered for everything ? If so - at a higher reimbursement ? The protons plan always look better. They might not be in actuality of course.

The proton plan does not "always look better," fwiw.

 

[radiaterMike]

The proton plan does not "always look better," fwiw.

True. But all proton plans submitted to insurers look better. I’d wager most look better vs IMRT/VMAT comparison plans that could be better optimized. I’d also wager that nearly all prostate proton plans lower dose to the rectum and bladder- but arguably not in a meaningful way. My point was that if minimizing normal tissue exposure is the only criteria for justifying need of a specific radiation modality then proton therapy would be indicated for all disease sites (and true -maybe not every patient as was seen in the esophageal cancer trial) - and ASTROs model policy would be legitimate. However, minimizing normal tissue exposure is not important unless it also equates to minimizing risks of damage. That is why we had to submit comparison plans for IMRT for Stage III NSCLC for years before policies were updated, and why even if we submit a plan comparison for a T3N0 rectal cancer the P2P will shrug their shoulders and say who cares it’s not really that much better. But if it were my pelvis I’d want IMRT. Would I want protons ? The plan would probably look better.

 

[medgator]

That is why we had to submit comparison plans for IMRT for Stage III NSCLC for years before policies were updated,

Evilcore gonna evilcore. They kept that policy in place until 2020, several years after the 0617 data was clear about IMRT

 

[RadOncDoc21]

I’m too lazy to look but is there any data comparing insurance company outcomes to each other?

One thing is for sure, they are making lots of money:

https://content.naic.org/sites/default/files/inline-files/2020-Annual-Health-Insurance-Industry-Analysis-Report.pdf

I believe data comparing insurance company outcomes is the only way to force them to consider advocating for better quality of care instead of focusing on how to make or save money. As the treating physician, we are held accountable and the first person the patient will blame.

 

[IonsAreOurFuture]

8 Gy x 3 SBRT is biologically equivalent to roughly 40 Gy. You will not be making the plan hot either due to the spinal cord in your PTV. Unlikely to improve in-field control compared to 30 Gy / 10

For slower growing tumors like prostate and breast, 8 Gy x3 has an EQD2 of 52.8 for a/B ratio of 3. For 3 Gy x10 the EQD2 is 36.

The patients live a long time so recurrence is common.

Nobody is going to give the equivalent of 52.8 Gy in 2 Gy fractions to the spinal cord, IMRT and/or SBRT is needed..

 

[IonsAreOurFuture]

Just had this one.

It also included the super pleasant, "I agree with you 100% and would do the same for my patient. But all I can do is give you a fax number for an appeal."

Good use of everyone's time. imo

Frequently the reviewer (usually not a practicing "peer" with training or experience in protons) will tell me that they lack the authority to overturn insurance policy.

Lacking authority is basically admitting that the whole P2P process is a scam designed to waste time and create a barrier to necessary care.

Why should we talk to another doctor if they are not allowed to make a clinical decision that's different than the one made by a nurse or computer algorithm?

If you like, you could document these for a future class action lawsuit.

I no longer do P2P calls, I usually just run out the clock when there is a 72 hr window for P2P, then appeal directly to the plan, then Maximus or the state insurance board, then an Administrative Law Judge if needed. I like the ALJs - it's a hearing with someone unbiased who has REAL authority to make the insurance pay.

 

[medgator]

Frequently the reviewer (usually not a practicing "peer" with training or experience in protons) will tell me that they lack the authority to overturn insurance policy.

Lacking authority is basically admitting that the whole P2P process is a scam designed to waste time and create a barrier to necessary care.

Why should we talk to another doctor if they are not allowed to make a clinical decision that's different than the one made by a nurse or computer algorithm?

If you like, you could document these for a future class action lawsuit.

I no longer do P2P calls, I usually just run out the clock when there is a 72 hr window for P2P, then appeal directly to the plan, then Maximus or the state insurance board, then an Administrative Law Judge if needed. I like the ALJs - it's a hearing with someone unbiased who has REAL authority to make the insurance pay.

Maximus. Forgot about them. I've usually had some luck with a secondary appeal with them before it ever gets to the state

 

[Pointless]

33 Gy vs 40 BED, strictly speaking. And no god forbid I do not work for Evicore

Yeah but... no. A quick trip to EQD2.com shows 8 Gy x 3 = 53 Gy with a/b=3.

EDIT: And I see someone else made the same observation a few posts up.

 

[IonsAreOurFuture]

Is not adding a level above and below for spine cases a terrible idea as well?

For palliative dose I no longer treat one level above or below, and I don't use 2D or AP-PA for spine. Usually I treat a 5 mm margin around the affected level(s), and typically use a 3 field beam arrangement with a PA and 2 posterior oblique wedge pairs. Dose distribution is a compact diamond shape around the vertebra.

There is a PRO paper from 4-5 years ago showing that treating AP-PA has a higher hospital admission rate for N/V, diarrhea, dehydration and failure to thrive, compared to 3D.

 

[CaesarRO]

For palliative dose I no longer treat one level above or below, and I don't use 2D or AP-PA for spine. Usually I treat a 5 mm margin around the affected level(s), and typically use a 3 field beam arrangement with a PA and 2 posterior oblique wedge pairs. Dose distribution is a compact diamond shape around the vertebra.

There is a PRO paper from 4-5 years ago showing that treating AP-PA has a higher hospital admission rate for N/V, diarrhea, dehydration and failure to thrive, compared to 3D.

My area is heavy on the p2ps, would not authorize 3D except for "soft tissue extension"

 

[Ray D. Ayshun]

My area is heavy on the p2ps, would not authorize 3D except for "soft tissue extension"

Tbh, I can rarely think of situation where I'm palliating a bone met that doesn't have "soft tissue extension." Once it hits that cortex, I think it's perfect valid so say that. At the same time, I really don't run into this issue. I do have trouble getting igrt with some companies.

 

[thesauce]

Frequently the reviewer (usually not a practicing "peer" with training or experience in protons) will tell me that they lack the authority to overturn insurance policy.

Lacking authority is basically admitting that the whole P2P process is a scam designed to waste time and create a barrier to necessary care.

Why should we talk to another doctor if they are not allowed to make a clinical decision that's different than the one made by a nurse or computer algorithm?

Agreed. I want one of these “reviewer” jobs.

“What are you asking for?”

“Sorry I don’t have the authority to do anything”

Bill. Rinse and repeat.

 

[seper]

Yeah but... no. A quick trip to EQD2.com shows 8 Gy x 3 = 53 Gy with a/b=3.

EDIT: And I see someone else made the same observation a few posts up.

I concede, perhaps a rare patient may benefit from post SBRT - remote history of GS 7 PCa, single T3 lesion posterior to the cord, good separation surgery

 

[seper]

Frequently the reviewer (usually not a practicing "peer" with training or experience in protons) will tell me that they lack the authority to overturn insurance policy.

Lacking authority is basically admitting that the whole P2P process is a scam designed to waste time and create a barrier to necessary care.

Why should we talk to another doctor if they are not allowed to make a clinical decision that's different than the one made by a nurse or computer algorithm?

If you like, you could document these for a future class action lawsuit.

I no longer do P2P calls, I usually just run out the clock when there is a 72 hr window for P2P, then appeal directly to the plan, then Maximus or the state insurance board, then an Administrative Law Judge if needed. I like the ALJs - it's a hearing with someone unbiased who has REAL authority to make the insurance pay.

You are describing such a long process. The entire system is trying to signal: do not push for protons, just send this T2N2 tonsil cancer down the street for IMRT. True, sometimes sheer stubbornness wins and physicians are trained to be good at stubbornness

 

[TheWallnerus]

You are describing such a long process. The entire system is trying to signal: do not push for protons, just send this T2N2 tonsil cancer down the street for IMRT. True, sometimes sheer stubbornness wins and physicians are trained to be good at stubbornness

Shouldn’t we be treating all T2N2 tonsillars with photons unless the patient is in a proton trial?

 

[sirspamalot]

You DO NOT want one of those "reviewer" jobs. P2P hate alone will challenge your ego. Megacorp will grind you with metrics, work! or be-gone. Enjoy your 2 weeks vacation. Your primary benefit is you have $ coming in and you can work from home. Yay.

Your pay? Lol. 240-275k W2 for every minute of your 40 hour work week. Don't forget to do your "off the clock" work like checking emails, doing internal QA work, and rewriting GL, attending mandatory meetings off hours, etc. That bonus? Maybe 5%.

Maybe you think you'll "win the pyramid game" and be one of hundreds plucked from obscurity (while working AT HOME) to get elevated to a higher title (with an extra 20, 40K a year). LOL. You'll never reach the top.

Just laugh..at yourself.. when you realize your CEO Megacorp boss is pulling 20-30M a year and your C-CMO is banking 3-5M.

As always, there IS a way to play this game and win that isn't exactly as above but.... trust me # brothers: you can be g-damned sure it exists.

 

[IonsAreOurFuture]

Shouldn’t we be treating all T2N2 tonsillars with photons unless the patient is in a proton trial?

The 2012-0825 MDACC-sponsored trial of oropharyngeal cancer that is comparing IMPT and IMRT just closed to accrual last year. 2 year data will probably show up at ASTRO 2024 as late-breaking presentations.

Like all randomized trials of protons and Xrays, it will suffer from crossover between arms due to insurance denial of protons and patient refusal of IMRT, making intention-to-treat analysis very difficult. Part of the patient refusal is that nobody goes to a major center to get the same H&N IMRT and cisplatin that they could get in Hometown USA. (assuming the current cisplatin shortage hasn't hit their hometown yet)

While waiting for that result, I believe there is already published data out of MDACC showing that protons reduce the risk of Gtubes and hospitalization. The proton patients cost more until about week 6 of a 7 week course; then the initial cost of IMRT plus an IMRT re-sim, re-plan and possible Gtube/hydrations/hospital stay leads to a tie with protons. Beyond that, the cost of long-term complications continue to accrue for both modalities, but at what rate? The 2012-0825 trial will help track long term events as well as stimulated salivary flow and other QOL metrics.

Compared to the dosimetric data from the early 2000's that showed IMRT could spare mean parotid dose better than 3D, and led to widespread adoption, I believe that the human data supporting protons relative to IMRT is already more robust, in my opinion.

 

[medgator]

Compared to the dosimetric data from the early 2000's that showed IMRT could spare mean parotid dose better than 3D, and led to widespread adoption, I believe that the human data supporting protons relative to IMRT is already more robust, in my opinion.

Of course you do. The price differential and equipment needs were much closer between the 3D and IMRT jump vs the jump from IMRT to IMPT. I remain skeptical the cost/price differential will ever be justified by the data. Plus when you consider things like the high ORN rate recently published it becomes even less clear

 

[sirspamalot]

That ain't just BBQ.. Smoked.

 

[Chartreuse Wombat]

The 2012-0825 MDACC-sponsored trial of oropharyngeal cancer that is comparing IMPT and IMRT just closed to accrual last year. 2 year data will probably show up at ASTRO 2024 as late-breaking presentations.

Like all randomized trials of protons and Xrays, it will suffer from crossover between arms due to insurance denial of protons and patient refusal of IMRT, making intention-to-treat analysis very difficult. Part of the patient refusal is that nobody goes to a major center to get the same H&N IMRT and cisplatin that they could get in Hometown USA. (assuming the current cisplatin shortage hasn't hit their hometown yet)

While waiting for that result, I believe there is already published data out of MDACC showing that protons reduce the risk of Gtubes and hospitalization. The proton patients cost more until about week 6 of a 7 week course; then the initial cost of IMRT plus an IMRT re-sim, re-plan and possible Gtube/hydrations/hospital stay leads to a tie with protons. Beyond that, the cost of long-term complications continue to accrue for both modalities, but at what rate? The 2012-0825 trial will help track long term events as well as stimulated salivary flow and other QOL metrics.

Compared to the dosimetric data from the early 2000's that showed IMRT could spare mean parotid dose better than 3D, and led to widespread adoption, I believe that the human data supporting protons relative to IMRT is already more robust, in my opinion.

If you want to suggest a degree of equipoise you might change your codename.

 

[TheWallnerus]

Like all randomized trials of protons and Xrays, it will suffer from crossover between arms due to insurance denial of protons

So inexcusable that insurance companies are the excuse, right or wrong, as to why we can’t answer any proton questions rigorously. Hey Siemens, IBA, etc… sponsor some GD trials.

 

[thecarbonionangle]

I believe i saw a quadshot a few weeks ago on an editorial about ORN proton paper. They went back and identified that most of those patients had older techniques. Maybe Im mistaken but i thought i saw this.

The protonists have a losing scenario. The same people who claim they want to see the data, are the same people who will claim that the cost is not worth it for such a mild improvement (“clinically insignificant”) with whatever endpoint is shown.
This is because they don’t have protons and never will so there is a COI there. Likewise, places that have this tech have a conflict of interest as well. Bottomline, i doubt the skeptics would ever be satisfied because it threatens their bottom line. i would imagine practices who did not have IMRT also said at some point it was not needed and not worth it!