Is SBRT covered by Medicare?

My 71 year old husband was diagnosed with prostate cancer last year. His 1st biopsy in Feb, 2017, showed 5 cores of Gleason 3+3. His PSA scores have been > 9 and < 9.6 for the past 2 years. He elected active surveillance and opted for a 2nd biopsy in Dec, 2017. This recent biopsy showed 3 cores of Gleason 3+4 (30%, 30%, and 50%) and 1 core of Gleason 3+3 (90%). Due to the change in his Gleason score, he has decided on radiation treatments. After much research, he would like to have SBRT performed by Dr. King at UCLA. The doctor has agreed to the treatment and his nurse navigator has contacted our insurance company to determine if prior authorization was required. Since we have a United Healthcare Medicare Advantage PPO, no prior authorization is required. After multiple phone calls to UCLA and United Healthcare, I am still not convinced that this is a covered procedure. Am I crazy?

United Healthcare tells me that if the treatment is covered by Medicare, then they will cover it. Has anyone had SBRT for prostate cancer in California and had it approved and paid by Medicare or United Healthcare Medicare Advantage?

Thanks - Rochelle

Thanks for the quick response. Though we are in a private Medicare Advantage plan, according to United Healthcare treatment for prostate cancer does NOT require prior authorization and that they will cover anything that regular Medicare covers. In addition, UHC puts the burden on the provider to request authorization (if required) in order to get paid. However, in order to get a guarantee, I may have to request UCLA get it prior to treatment. Any thoughts?

Here's what United Healthcare Medicare Advantage policy says:

"SBRT for Prostate Neoplasms
SBRT of the prostate is covered for patients with clinically localized low to intermediate risk prostate cancer on an individual case by case basis."

/www.unitedhealthcareonline.com/ccmcontent/ProviderII/UHC/en-US/Main%20Menu/Tools%20&%20Resources/Policies%20and%20Protocols/Medicare%20Advantage%20Policy%20Guidelines/Delivery_IMRT_SRS_SBRT.pdf

But I know that it is covered by Medicare at UCLA.

(this is OT)

JNF-

You may be interested in this AMA research on prior-authorization. Doctors hate it, as we all do.

/www.ama-assn.org/sites/default/files/media-browser/public/arc/prior-auth-2017.pdf

The question is - how do we get rid of it and still keep medical costs affordable? It seems to have the unintended consequence of actually raising medical costs - doctors and their staffs spend 15 hours/week on it, and a third of doctors have to hire staff do do nothing but request and appeal them. Is there a way to speed up the process so it doesn't delay necessary treatment? Is there something to be done about unqualified people rubber-stamping "no" and forcing time consuming appeals?

Break, thanks for the info, but that doesn’t mean they will have 100% coverage. Thus my suggestion that they confirm the coverage first.

TA, I understand, but we are talking about the specifics of this case. I suggest they get a determination they can count on. Or they can take someone’s word for it and may be disappointed.

Remember, before the treatment begins the patient will sign a form that confirms the he and he only is responsible for 100% of the cost. Intake such a declaration very seriously and want to clearly know what I am committing to.

TA, it appears that the biggest mystery in health care is procedure cost. The consumer has no idea and there is no consistency among providers or among payers for reimbursement of similar procedures. There should be a system somewhat similar to car body shop estimates and car insurance approvals. There appears to be congruence among shops and insurance companies that narrows the costs and reimbursements. This doesn’t exist in healthcare.

In the absence of transparent pricing in medical services, I think we have little choice but to require a cost determination and reimbursement before treatment. We do that in most every other large ticket transaction, why not medicine? It won’t work on everything, but could at least 85% of the time. And if the providers don’t like it then they can develop systems that are cost effective and meet the the needs of the patient. Very normal procedures are costing $25-$50k and we wait for the EOB to see what it might cost us? Would you embark on a $50k home improvement without a detailed estimate, construction contract, and having done some competitive pricing research?

Of course this came about over the last 80 years as employer sponsored health insurance and the Medicare took the patient out of the equation. Who cares what it costs if I am not writing the check? In the last 10 years more people have to buy their own insurance and employer sponsored plans have exploded the deductibles and co-pays. Ten years ago I bet the average employed family in the US needed to budget no more than 4% of income to cover premiums and healthcare costs. Now they are approaching 10-15% and for many and is a real shock. Wages have been relatively stagnant and now many people spend more on healthcare than housing. As a co-owner of a business, most of us have a direct expense of nearly $25,000 per year for premium and deductibles.

But I digress. If the cost to the provider of providing approval and determination is excessive, then take the financial risk off the patient. If the insurance company doesn’t cover the cost, then the provider eats the difference. But if I am responsible for the cost, I will demand a determination that will stand up legally before I agree to the procedure.

I INSIST on a written pre-auth for anything that even remotely requires one. Usually this has to be some days before scheduling. I have had two cases with UHC where they refused to pay, but when confronted with a printed doc, they backed down.

I have an agent working on Medicare with me, and they advise that they will drive a similar "get it in writing" policy with Medicare for me.

But experience tells me that if I don't have it in writing, and it costs real money, it ain't gonna happen.

Dandrhuff,
Back to your original issue. . .

I was not on medicare at the time of my SBRT treatment, but I was in a UHC group plan. My RO was very familiar with the pre-authorization procedure for UHC. Her office did the entire pre-authorization process before we scheduled the procedures. It only took them a few days. Once they had it all under control, we scheduled all the prep work and the treatments.

The whole process went totally without a hitch for me. Since we also had BCBS secondary coverage at the time, I don't remember having to pay anything out of pocket. Beware, though, as I seem to remember that the total package cost was in the $100K range. Thankful for good insurance coverage. . . again.

Send him my best. He's been mentoring Amar Kishan, who is equally impressive. Between the two of them, and including guys who have used them for primary, salvage, brachy boost, or SBRT to bone mets, I would estimate that half the men in my live support groups have used them and are very happy they did.

I have touched base again with UHC. They reached out to UCLA and confirmed that all the CPT codes for the treatment plan are covered by our health plan. This has been documented in my husband's insurance records. We feel we have done our due diligence and will leave the rest up to UCLA and UHC.