Sample Letter in Response to Non-Coverage of IMRT by a Private Payer
Dear Dr. :
The American College of Radiology (ACR) Managed Care Committee (MCC) understands, from information you provided and from previous discussions with ACR staff, that a payer in your state has recently started classifying Intensity Modulated Radiation Therapy (IMRT) as an investigational medical service. We understand this payer’s current policy statement concludes the use of IMRT in the treatment of cancers is not supported by peer-reviewed scientific literature, and states that additional research is needed to determine health outcomes as compared to other treatments, such as conventional radiation therapy, stereotactic radiosurgery, and "conventional" 3D conformal radiotherapy techniques.
The ACR does not agree with this policy and has taken a stand to firmly support the use of IMRT applications in certain situations. Under specific parameters, IMRT is not considered investigational for all indications. IMRT applications have been developed over the past ten years and are well accepted in the medical community. This is evidenced, in part, by Food and Drug Administration (FDA) approval of IMRT technology and Medicare coverage of this medical service.
Currently, the ACR supports the application of IMRT as a medically necessary, non-investigational procedure that is indicated for primary brain tumors, brain metastasis, prostate cancer, lung cancer, spinal cord tumors, head and neck cancer, pituitary tumors and situations in which extremely high precision is required. In addition, there are clinical situations in which IMRT may be appropriately used to retreat a previously radiated area. For example, retreatment of spinal cord sparing, spinal epidural metastasis and pelvic recurrence, colorectal and endometrial in previously treated radiation therapy should be recognized as an appropriate indication for use of IMRT. Nonetheless, the ACR maintains a firm position that IMRT is not a replacement therapy for conventional and 3D conformal radiation therapy methods. Further, the ACR believes that controls should be placed on this technology, to a degree, to avoid its abuse.
The decision process for using IMRT requires an understanding of accepted practices that take into account the risks and benefits of such therapy compared to conventional treatment techniques. While IMRT technology may empirically offer advances over conventional or 3-dimensional conformal radiation, a comprehensive understanding of all consequences is required before applying this technology. IMRT is considered reasonable and necessary in instances where sparing the surrounding normal tissue is essential and the patient has at least one of the conditions outlined in Attachment A. IMRT makes possible conformal radiation dose distributions to the target while reducing exposure of adjacent nontarget structures, beyond the capabilities of traditional two-dimensional or even state-of-the-art three-dimensional treatment techniques, thus reducing complications.
The ACR recognizes the need to monitor the use of IMRT and finds the use of rigorous documentation requirements an appropriate mechanism to help assure appropriate application of IMRT for all indicated situations. Please see Attachment B for a copy of ACR-recommended documentation guidelines for all uses of IMRT.
IMRT is not an investigational technology and has been reviewed and approved by the Physicians Current Procedural Terminology (CPT®) Editorial Panel. The IMRT CPT® codes (77301 IMRT plan, per session and 77418 IMRT delivery to multiple areas with treatment setup and verification images.) are classified as category I codes. For a procedure to be considered as a Category I code, it is required that the service or procedure be widely accepted in the medical community, that FDA approval of a drug or device associated with the procedure be documented and that the service or procedure has proven clinical efficacy as evidenced by peer-reviewed journal articles. As you are aware, the CPT® system was chosen as the national standard code set by the Centers for Medicare and Medicaid Services (CMS) in August 2000 as a single coding system was mandated by the Health Insurance Portability and Accountability Act (HIPAA) of 1996.
The CMS also supports the use of IMRT as a non-investigational procedure. CMS has established Medicare reimbursement for IMRT in the Medicare Physician Fee Schedule Final Rule for calendar year 2002 (42 CFR 55423, 55424), please see Attachment C. The American Medical Association (AMA) RVS Update Committee (RUC) reviewed the (CPT®) codes for IMRT and submitted a recommendation to CMS for inclusion in the 2002 Final Rule. The CPT® codes for IMRT have been included in subsequent Medicare Physician Fee schedules and this medical service is available to Medicare beneficiaries when appropriate and necessary. The ACR maintains a position that, at a minimum, enrollees of private health plans should have access to the same health care options as Medicare beneficiaries.
The ACR is sensitive and respectful of the need to control the cost of health care and avoid unnecessary procedures. IMRT however, is a viable non-investigational treatment modality and is recognized and covered as such, by CMS, is approved by the FDA and has received a category I CPT® code classification. Also attached for your reference is a list of sources on IMRT and the ACR Technical Standard (previously referred to as the ACR Standard) on IMRT, you will note this Technical Standard also includes a list of references. The ACR encourages private insurers to recognize the value of this advancement in radiation therapy, and to allow its enrollees access to the same care that this country’s Medicare population receives.
We are happy to provide you with further information, or discuss this matter further with you, at your discretion. Please contact Angela Stanley at the American College of Radiology (800-227-5463, ext. 4560) if you have additional questions.
Sincerely yours,
Christopher G. Ullrich, M.D.
Chair, ACR Managed Care Committee
Louis Potters, M.D.
Radiation Oncologist, ACR Managed Care Committee
Enclosures
Cc: John A. Patti, M.D. Chair, ACR Commission on Economics
Rachel Kramer, ACR Director, Economics & Health Policy Department
Angela Stanley, Analyst, Economics & Health Policy Department
