IMRT is the de facto standard of care for the treatment of definitive disease
Prior authorization denials for IMRT in definitive cancer treatment cases should be an embarrassment to everyone in cancer care.
Reality: Reality can often be quite different from a simple post or article. Sometimes, one must play by a set of rules that is inherently unfair or unjust - it’s often phrased as “working within the system” - I get that. But at the same moment, we still need to have discussions about where a more idealistic and just answer lies. Today is the opinion of one of where I think reality should lie for insurance authorization of IMRT for the definitive management of nearly every cancer diagnosed in 2024.
Finally, to be clear, this is an article on 3D vs. IMRT. I know you’re on a “proton” site but everything here is attempting to raise the minimum bar for definitive treatments from the old standard of 3D to IMRT. And so, we begin:
A Tale:
Imagine for a moment that you are on the insurance side of the authorization process. There is a questionable “gray zone” in the definition of the billing code. There is no “perfect” answer - within the regulatory environment - after all, many things carry nuance.
Now imagine that the insurance company takes the following approach:
anything in the gray zone should just get approved - in the interest of patient care.
It is really funny to even consider. Of course this isn’t how our market works. If it is gray, it is denied - nearly by routine and then if you jump through hoops and appeal and document and “demonstrate” proof, then it can be considered.
Today, I’m going to walk through IMRT for the treatment of definitive cases and show just how much we allow insurance companies to dictate care. And “we” allow it.
(By we I mean: everyone in the clinic collectively along with our specialty representative organizations, to the insurance companies, to the employers who don’t lean on the insurance companies, to our elected officials that allow it to continue.)
And I hold the physicians and our specialty boards the most responsible as they are the most informed to the science. We rationalize it and we attempt to play by their rules. When in reality, just about everyone - regardless of location or party - would believe that physicians and patients should be making these calls.
And with that brief introduction, let’s go a bit deeper.
IMRT started its roll-out back in the 90’s. Computer optimization of the dose beyond what people could just “come up with”. Each beam, instead of just one block pattern, might have 20 different beam patterns. Use 5 or 7 beams and what once was the blending of 2 or 4 patterns in the 3D world would now be the blending of 100 or more patterns. It’s like making the picture 16-bit color and removing pixels - it ain’t the same.
But this is far more important than an image - we’re talking about cancer treatment.
Consider the patient perspective:
A once in a lifetime (hopefully) event. Staring down a cancer diagnosis with realistically ONE good shot for cure. The diagnosis and treatment of a disease which will be one of the foundational events for this person during their journey on this earth.
I can’t write strong enough words…
We are discussing radiation delivered at super high doses to a cancer immediately adjacent to a critical normal structure than can be damaged. The goal is to attempt to cure the patient while minimizing toxicity. If your doctor can create the subtle differences on the left, do you think an insurance company should dictate that picture on the right is “good enough” - based on costs? Judgements based on rather arbitrary assignments of dollars to CTP codes are the literal rationale for decreasing the precision of the radiation given to the patient - to “decrease” insurance outlays - or more precisely stated, to increase potential earnings.
What an absurd argument.
And proof? We’ve done the work - about a dozen times in randomized prospective trials demonstrating that we should put dose where it is required and not put dose elsewhere. I document many of them here:
And yet, decades later, insurance companies are still denying the improvement of the resolution of the radiation that we use to cure cancer. They just flat out deny the patient the plan where we can deform the dose to the target - be more specific and precise with where the radiation lands. They argue “costs” and “lack of clear benefit” but seriously?
It is simply crazy….
And we play by their rules:
We get lured into playing the game - not on behalf of the patients - but according to “insurance rules”. Think about what we do. And I’m purposefully starting with the one of the more “controversial” sites.
An example:
Tangent breast treatment with multiple forward planned segments.
If you know anything about laws and regulations, you understand that language is not perfectly precise. There is no way to account for every situation and so documents get translated to “real-world” application through the law system - maybe people have ideas about what they think the words on the regulation mean, but truly the rubber meets the road in the courtroom leaving many of these areas quite “gray”.
And so back to the example - forward planned breast treatments. For whatever reason, in a gray zone of recommendation and regulations, we (our professional society) has chosen to argue that forward planned tangents are 3D treatment. Certainly this was trying to be “moderate” or “prudent” when this trend started 15-20 years ago but it is striking to me just how different our approach is from an insurance company approach. Again, in our own literature, scientific papers will call this type of approach intensity modulated radiation - the intensity of the beam is modulated - literally.
This approach is 1) dramatically safer than wedged treatments and 2) far more homogeneous than prior approaches. It is a fundamental component of our ability to treat women faster and quicker with fewer and fewer long-term toxicities. I don’t really care what you call it, but it falls under “progress.” And yes, I’m old enough to have years of experience with our older 3D approaches even back to the good ol’ days of back-pointers and papier-mache contours (different tale, different day).
Yet, we fall into theoretical debates regarding the issue of forward vs. inverse planning? It comes down to an argument over “how the leaf segments are created”. Really?
Soon it will be within the box of “AI” generated and we’ll honestly have no idea how the computer got to the solution.
And it shouldn’t matter, and we should not care. And yet, we take the arbitrary stance of being “noble” in attempting to separate the two approaches for the benefit of insurance companies? Or payment models? Is that really our goal?
I’m being a bit sarcastic obviously, but “reality” is just as bad. In reality, it is playing with politics and dollars. The “real” answer is “we” worry that if we billed this as IMRT, the IMRT might be adjusted or costs might rise just a wee bit faster thus causing some other unforeseen outcome because we think the insurance lobbies will push back or Medicare will push harder for an adjustment of the IMRT payment code. We play a game in our own heads of trying to pick - not the best clinical answer - but the “best” financial answer.
And when you type this out or say them out loud, are the two versions really that different?
In my view, not really. In either case are we truly advocating for the patient? In either case are we really advocating for better? No. Rather, in both cases, it is about the money. In both cases, it is approximating the approach of an insurance company rather than being a representative and advocate for our patients. If billing payment differences are the sole determinant of approach, then fix the codes or payments or both and work simply on better treatments.
As physicians, we should stick to being advocates for our patients and then fight like stink for the value we provide. At least that is my perspective.
In the insurance world, they hired MDs to deny requests. Why? Because MDs yelled at MDs on the other end of the line less. It wasn’t some good deed. It was about money and rejecting more claims more easily. And when that stopped really working as well as they liked, they “out-sourced” that entire aspect of their business to companies like "he who must not be named”.
They didn’t hire these third parties to pay out more claims, they did it to increase their ability to not pay for stuff. It was another legal layer - a way to increase asset protection - nothing more, nothing less. Like moving your real estate holdings to a separate LLC - same thing, create layers that accomplish legal protection.
Meanwhile, we argue that drastic changes in the planning of breast cancer - that significantly improve patients outcomes - that allow us to use shorter and shorter course of treatment - that are safer, don’t rise to the standard of IMRT “just ‘cause” of how you designed the segments. Rather than view the progress as a glass half-full, we view our own progress as half-empty and fall into the trap that the insurances have set up for us.
Before moving on - I do want to acknowledge that to every rule there are exceptions. There are many people working within the auth industry trying to make the system better and there are large players, likely trying really quite hard, to continue to improve the system, but by and large, pre-authorization within cancer management - targeting radiation by denying IMRT for definitive care cases is not that - at least from my perspective.
It gets worse:
“Give us the specific data - randomized - phase III data for ICD code xx.xxx showing that IMRT is clearly required in this specific scenario.” asks the insurance carrier.
And we fall over them writing our model policies along these very lines - item by item. Reference by reference. ICD code by ICD code.
It is as if, looking at the image above, the argument becomes:
“Well yes, I can see that a sunset picture of a lake is in fact better, but what it was simply a snowy mountain? - where is your randomized trial for a series of snowy mountain pictures being superior - I mean there is far less color contrast isn’t there?”
And our response perpetuates the error downstream for years. By attempting to keep up with references and creating a line item defense of such a basic position, WE are locking in old standards. Today there is no way to keep such a structure up to date. Each year we likely generate hundreds of new data points for each disease site. Medical literature is moving far too fast to play this game that was built, setup, and constructed by the insurance industry to save money.
A “reference” document today will literally be out of date by the time it is adopted - locking in old patterns of care - contributing, not to the advancement of our field, but to profits based on patterns of care from yesterday. It turns into a lagging 2 - 5 yr cycle of repeated efforts to alter the language and the regulations to get patients what they deserve - really great treatment that is readily available.
Instead, paperwork begets paperwork. And jumping through hoops leads to time delays. And time delays equate to dollars - not in some rather abstract fashion - but in a clear dashboard metric kind of linkage for the insurance carrier.
And, finally, what are they selling?
When insurance teams are selling these policies, do you think this is what they advertise? No.
No one would walk into a meeting with the HR team of the institution and tell them that they liked to put up administrative hurdles to make access to care more difficult. “One of our main drivers of profit within the cancer market is by routinely denying IMRT radiation when it hasn’t been proven for a specific disease site.” That is a crazy argument. It is a fraction of a fraction of the spend on single drugs. And somehow we’ve convinced ourselves not to move the bar simply to where it should be - thinking that we want to be good stewards and not allow the “fraudulent” use of IMRT to treat a definitive case.
Yet, today we stand on the correct side if we shift the framing. I truly believe that if the financial stakeholders of the insurance companies understood the issues at hand, I believe these types of denials would stop immediately. I don’t believe hardly anyone in America would support this type of policy publicly if we advocated for fair and correct usage policies for all definitive cases.
It is our job to clearly ask our representatives to fight in support of our patients. We must be their strongest advocates in their fight.
What got me here?
I was on a call with two colleagues. One had been denied the use of IMRT by an insurer for a large central lung cancer with a contralateral lymph node.
The argument was, since they were not getting concurrent chemotherapy, IMRT wasn’t clearly proven better. Ah…. I guess. I’m honestly thankful that, as a young man, I opted to do what I do. Looking for ways to not pay for common sense stuff for cancer patients isn’t what I’d look back upon and be proud of.
Next case was a head and neck case - a T2 unilateral lymph node positive case. I mean please. You cannot be serious - 3D? with what? electron strips posteriorly?
These are gross errors - they are basically levels of malpractice, but this is standard and it happens daily. In my assessment we have been far too compliant and complacent in allowing them to dictate these types of decisions to a “flowchart”.
Don’t get suckered into to asking - “did they ultimately get approved?” If that thought even crossed your mind, I’d ask that you really reconsider the issues. We’ve all been duped into seeing this as reasonable, when, if you back up, it is not.
We should push back and state what is clear. I don’t think it is that hard. This should be our stance. Period.
IMRT is the de facto standard of care for all definitive radiation cases.
From that starting position, we have a new and appropriate standard. If you want to carve out non-melanoma skin cancers and perhaps a few other rare exceptions that is fine, but we need to move the goalpost and quit playing by insurance rules designed for one primary reason - to generate income for stakeholders - a very specific cohort of stakeholders mind you - the ones holding stock or debt in the insurance companies.
And that is why I wanted to specifically address the carve-out of forward planned tangent treatments. It is an approach that today one might consider either as 3D with multiple devices or IMRT where multiple code edits occur. The reality is, the costs differences aren’t that great and the simplification of the broader argument for IMRT becomes much stronger and less nuanced if you make that one simple adjustment to our approach - an approach where “we” (our representative societies) seem to take an anti-radiation position in a muddy region of the codes.
I believe that if we moved the bar simply to where it should be, and stated clearly that the standard is IMRT, then patients and their attorneys would be able to clearly understand the state of our data today. IMRT is superior to 3D - like the picture - clearly and bluntly better.
(and it’s moving towards this in the palliative setting as we dose escalate and hypofractionate but I wanted to keep today’s discussion clean)
I believe this is a patient advocacy effort that is reasonable to undertake today. Maybe there are a few exceptions to this rule, but they are far less than the indications - by a factor of magnitude. We have the opportunity to lead for our patients and we should unify our voice to push for these basic approaches that we, in the clinic, all know are valuable.
Is there fraud and abuse in the system? Certainly, but does 100’s of hours debating specific language regarding Stage IIIB lung cancer (without chemotherapy) or unilateral head and neck cancer help stop fraud and abuse? No.
In fact, to the contrary, the wasted time on reasonable indications probably leads to more opportunity for abuse due to the waste in resources. IMRT for the definitive treatment of cancer is NOT fraud and abuse in America in 2024. I proudly stand by that statement in support of the patients I treat.
Medicine needs physician leadership. The layers of administrative bureaucracy often don’t understand just how basic and simple this is. It is about putting the radiation where we need it to go. For curative cases, this is simple. We are twenty to thirty years in - patients deserve not to have denials for such basic services that we, if moved to the patient chair, would all mandate.
Thanks for what you do day in and day out. Let’s keep pushing for better.