T. C. Mullikin, Z. J. Reitman, and J. P. Kirkpatrick; Department of Radiation Oncology, Duke University Medical Center, Durham, NC
Purpose/Objective(s): Medicare Advantage is a capitated payment model for Medicare Advantage Organizations (MAOs) to provide Medicare services in the United States. Under CMS rules, MAOs are required to offer coverage that meets or exceeds the standards set by Medicare Parts A and B with actuarial equivalence. Per the Medicare Managed Care Manual, MAOs must make determinations based on the medical necessity of covered services, which are “no more restrictive” than the original Medicare national and local coverage determinations (LCD) policies. Herein, we evaluate coverage determination policies for stereotactic radiosurgery (SRS) for brain metastases (BM) amongst our institution’s local Medicare LCD and MAOs. Materials/
Methods: We identified and reviewed the CMS LCD and MAO policies specific for SRS coverage for BM for our region/state. MAO policies included Cigna, Aetna, UnitedHealthcare (UHC), Humana, and Anthem. Of note, policies for Cigna and Aetna are under third-party utilization management, UHC uses its commercial policy if no LCD is present, and Humana refers to LCD guidelines with supplemental criteria for coverage determination. CMS LCD L39553 was used as the comparative standard and considers SRS for BM medically reasonable and necessary under two scenarios – new BM and repeat BM therapy. For new BM, coverage required good performance status (PS) (KPS=70 or ECOG 0-2), absence of leptomeningeal metastases (LMD), and not having a primary diagnosis of a lymphoma, germ cell tumor, or small cell carcinoma (i.e. histology). For repeat BM therapy, additional LCD criteria were stable extracranial disease and life expectancy of > 6 months. A separate indication for SRS was relapsed in a previously irradiated cranial field to avoid normal tissue injury. Results: We identified 5 separate MAO policies. For new BM, MAO criteria for SRS coverage included good PS (5/5), histology (4/5), and no LMD (4/5). Additional non-LCD criteria included extracranial disease control/systemic therapy options (4/5), number/volume of lesions (3/5), and size of BM lesion (1/5). For repeat BM therapy, additional LCD criteria of stable extracranial disease (or systemic therapy options) (4/5), life expectancy > 6 months (1/5). Additional non-LCD criteria included the total number of BM over 12-month period (3/5). Four of 5 plans explicitly listed coverage for SRS for BM following WBRT. For postoperative SRS, two MAOs listed additional criteria of up to 4 resected and unresected lesions < 5 cm. Conclusion: While there is considerable agreement for coverage determination criteria for SRS for BM amongst our local LCD and MAOs policies, there are notable differences with additional MAO criteria including potential future systemic therapy options and the number/volume of BM. In some patients, these additional criteria may be more restrictive than CMS coverage guidance and lead to inappropriate coverage denials. Efforts should be made by CMS to ensure compliance by MAOs with best evidence.
