AllMed Webinar Helps Health Plans Learn About the Medical Necessity of IMRT for Certain Cancers

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AllMed webinar provides health plans with the latest information on when IMRT is medically necessary in cancer radiation therapy.

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Ongoing innovations in radiation therapy present the challenge for healthcare policy-makers and providers to develop the most effective, efficient, and safe treatments for patients

Data supports the use of Intensity-Modulated Radiation Therapy (IMRT) to optimize outcomes and reduce toxicities for certain cancers, but the procedure has recently come under government scrutiny for its high cost and because some physicians refer patients to facilities in which they have an ownership stake. During a recent AllMed webinar, Dr. O. Kenneth Macdonald, a radiation oncologist, discussed issues related to determining medical necessity IMRT, including complications associated with this high-precision radiation delivery system.

IMRT utilizes computer-controlled linear accelerators to deliver precise doses of radiation to a malignant tumor or specific areas within the tumor, Dr. Macdonald stressed that IMRT is not a replacement therapy for conventional radiation therapy methods. He described certain conditions that may require IMRT. For example, IMRT may be used when an immediately adjacent area has been previously irradiated and abutting portals must be established with high precision. Dr. Macdonald noted that IMRT is most extensively used to treat cancers of the prostate, head and neck, and central nervous system. It has also been used in limited situations to treat breast, thyroid, lung, gastrointestinal, and gynecologic malignancies, and certain types of sarcomas.

IMRT allows higher radiation doses to be focused to the regions within the tumor while minimizing the dose to surrounding critical structures. It is generally associated with fewer side effects than conventional radiation therapy. General side effects of radiation therapy include short-term side effects, such as fatigue, hair loss, and loss of appetite, and more serious long-term side effects, such as infertility, joint changes, lymphedema, and secondary cancer.

Dr. Macdonald reviewed a number of National Comprehensive Cancer Network (NCCN) guidelines that discuss the use of IMRT. Most recently, the 2014 NCCN guidelines on prostate cancer included a number of statements regarding treatment with IMRT. The NCCN has also made recommendations on the use of IMRT for breast cancer. The use of IMRT for other cancers, such as rectal cancer, cervical cancer, pancreatic adenocarcinoma, and gastric cancer, generally remains investigational for these cancers.

Many healthcare plans cover IMRT when very specific conditions are met. Dr. Macdonald cautioned that while advances in imaging techniques and computer software have allowed more accurate targeting of tumors and have improved outcomes and quality of life for patients with cancer, they have also led to overutilization of new technologies. “Ongoing innovations in radiation therapy,” said Dr. Macdonald, “present the challenge for healthcare policy-makers and providers to develop the most effective, efficient, and safe treatments for patients, as well as to integrate these innovations into routine practice, guidelines, and coverage.” It is, therefore, critical for healthcare plans to position themselves to keep up-to-date on clinical guidelines and new technologies and applications, which may play a key role in reducing overutilization.

About AllMed
AllMed Healthcare Management provides physician review outsourcing solutions to leading health plans, medical management organizations, TPAs and integrated health systems, nationwide. AllMed offers MedReview(sm), MedCert(sm), and MedDirector(sm) staffing services that cover initial pre-authorizations and both internal and external appeals, drawing on a panel of over 400 board-certified specialists in all areas of medicine. Services are deployed through PeerPoint(R), AllMed's state-of-the-art medical review portal. For more information on how AllMed can help your organization improve the quality and integrity of healthcare, contact us today at info(at)allmedmd(dot)com, or visit us at http://www.allmedmd.com

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Kiki Grant
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