TRICARE Deletes Compensator-Based IMRT from Government No Pay Code List
Sanford, Florida - Effective September 2, 2008 TRICARE has removed compensator-based IMRT delivery (CPT 0073T) from the “No Government Pay Procedure Code List” (http://www.tricare.mil/nogovernmentpay). The “No Government Pay Procedure Code List” is a list of codes that are excluded from coverage and are not payable under the TRICARE program.
Based on the recent removal of 0073T from the “No Government Pay Procedure Code List”, .decimal anticipates that providers will be reimbursed for compensator-based IMRT delivery effective September 2nd.
Previous to this decision, TRICARE had taken the position that CPT code 0073T for compensator-based IMRT delivery is “unproven and experimental.” In 2007, two .decimal customers filed an appeal against TRICARE’s position. In response to these appeals, the Judge’s recommendations were finalized on May 27, 2008.
A partial summary of the Judge’s findings:
“After careful consideration of the hearing file, the testimony elicited at the hearing, and the arguments made by the parties, I recommend that TRICARE pay the claim at issue in this case. TRICARE covers MLC-based IMRT. Compensator-based IMRT is equivalent to MLC-based IMRT. The locally issued, but uniform Medicare coverage policy to pay for compensator-based IMRT, notwithstanding its 0073T CPT Code, provides some support for TRICARE coverage. The National Cancer Institute’s policy of accepting compensator-based IMRT and MLC-based IMRT on an equal basis for clinical testing constitutes reliable evidence of a uniform national policy. ASTRO’s policy towards compensator-based IMRT, while not explicitly endorsing this treatment methodology, does implicitly support its use in ASTRO’s model treatment plan of 2007. The American College of Radiation Oncology (ACRO) in 2004 concluded the two methods are scientifically equivalent. The NCI, ASTRO, Medicare and ACRO policies are “published national medical policy organization positions,” and meet TRICARE’s restrictive “reliable evidence standard. Most importantly, there was unrebutted evidence that MLC-based and compensator-based IMRT provide comparable radiation doses to healthy tissue and cancerous tissues.
(1) Compensator-based IMRT beam treatment is proven to be safe and effective under the requirements of TRICARE regulations.
(2) Compensator-based and MLC-based IMRT beam treatment have not been the subject of well-controlled studies of clinically meaningful endpoints, as defined by TRICARE regulations. Such studies have not determined their maximum tolerated dose, toxicity, safety or efficacy as compared with standard means of treatment or diagnosis. Nevertheless, TRICARE has appropriately covered MLC-based IMRT beam treatment.
(3) There is a consensus among experts that further studies or clinical trials of compensator-based IMRT beam treatment are not necessary to determine its maximum tolerated doses, toxicity, safety, or effectiveness as compared with the standard means of treatment (MLC-based IMRT beam treatment) before it should be used in clinical trials and it should receive Medicare and TRICARE coverage. However, further study of IMRT beam treatment is worthwhile and will likely lead to continued improvement of radiation treatment.
(4) Compensator-based IMRT beam treatment (CPT code 0073T) and MLC-based IMRT beam treatment (CPT Code 77418) are sufficiently similar to reasonably result in both treatments being proven.”
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.decimal is a medical device manufacturer of patient-specific devices, including missing tissue compensators, modulators for advanced IMRT delivery, as well as apertures and range compensators used in proton therapy. The company has been providing radiation therapy products for over twenty years. For more information concerning .decimal, please see its Web site at www.dotdecimal.com.
