by Kelley Regan Costello, Fotheringill & Wade, LLC
To improve cancer survival rates, the number of providers relying on the use of intensity-modulated radiation therapy (IMRT) to treat breast cancer and other forms of cancers is growing. An unwanted consequence of the increased use of IMRT is an increase in the number of denials for IMRT treatment.
Issue: Often authorization requests for IMRT are denied as experimental and investigational because many of the clinical policies insurers rely on to deny IMRT claims are based on outdated clinical sources which do not account for the most recent advances in IMRT. Until insurers policies adequately (and accurately) account for the most recent clinical advances, providers will continue to face denials for the use of IMRT in the treatment of breast cancer.
Takeaway: IMRT denials often based on policies which reflect outdated clinical sources. When faced with denials for IMRT, specific clinical facts and documentation that support the service provided, combined with current clinical studies which document the recent advances and benefits of IMRT, can form a strong argument for an overturn of the denial.
To help facilitate and ensure the providers successfully overturn denials upon appeal, please consider the case study below and the means by which a provider can overturn similar denials despite an insurer’s outdated policy.
Denial Reason: Commercial insurance payer denied provider’s request for authorization for IMRT treatments as “experimental and investigational.”
Case Facts: 30 year old woman diagnosed with breast cancer after an ultrasound showed a 2.7 cm irregular mass in the left axilla, with abnormal appearing enlarged lymph nodes. Fine needle aspiration showed adenocarcinoma with metastatic adenocarcinoma in the lymph nodes. Patient underwent a partial mastectomy. A needle biopsy was positive. Patient underwent chemotherapy and subsequently, presented for five (5) IMRT treatments, which was a successful approach for this patient.
I. Use the outdated clinical policy information to your advantage.
Under this patient’s specific health plan, the insurer’s IMRT policy is based on studies conducted in 1999 and 2002, a veritable lifetime ago when measured in the lifecycle of medical technologies. The cited studies claim that it is not clear if the improvements achievable with IMRT will lead to significant clinical outcome improvements and further that IMRT offers no clinical advantage over standard therapy. While this may have been true when the studies were conducted, recent studies will show that this is no longer the case.
Recent research shows that IMRT is almost universally accepted as being superior in reducing the side effects of radiation, such as reducing heart diseases, reducing recurrence rates and second malignancies. Use this updated and accurate clinical information to refute the denial contention that IMRT is experimental and investigational. Let the clinical research argue for you to show that the IMRT outcomes are better because higher doses can be delivered in the tumor, targeting volume while reducing dose to critical organs in the surrounding areas.
II. Approach each appeal on a case-by-case basis.
Each case is unique and a thorough review of the medical records is required to identify the necessary clinical facts, such as patient’s history and treatment, that support the service provided. In our case study, because of the patient’s positive axillary lymph nodes, the proposed method of treatment was irradiation of the breast/chest wall and regional lymph nodes. An appeal could argue that it is considered reasonable and medically necessary to spare the surrounding normal tissue (i.e. cardiac and pericardial structures, lung, spine, and other vital components of the body), a recognized objective of IMRT. This patient required CT guidance for placement of the radiation therapy fields to determine the normal tissues around the treatment area that needed to be blocked from irradiation. Through IMRT, a more accurate volume of the treatment field can be determined in higher doses for the patient, to decrease radiation delivery, which is yet another reason to support IMRT for this patient.
III. Evaluate the success of the treatment.
Was receiving IMRT treatment critical to this patient’s survival? Did it work? Providers are seeing overwhelming amount of success with these IMRT cases every day. If IMRT treatment was successful, highlight the success of the treatment in your appeal.
Modern medicine has shifted in the direction of IMRT as a means for treating breast cancer. Clinical research and studies have become more prominent proponents on this treatment of this proven benefit. Providers should not be denied reimbursement simply because insurance companies are slow to adopt the new, effective technology, especially since it’s suited for treating these patients in order to yield better and more positive results. Ultimately, an IMRT denial should not discourage providers. Appealing in these cases is the right thing, you can win the IMRT denial appeals and continue rendering successful and reliable treatment while using the “state-of-the-art” radiation while generating revenue in these cases.