The CyberKnife® Robotic Radiosurgery System was cleared by the U.S. Food and Drug Administration (FDA) in 1999 to treat lesions and tumors in the brain, spine, head and neck. In 2001 it received clearance to treat tumors anywhere in the body. With its ability to deliver radiation with extreme precision, the CyberKnife System is being used around the world to treat a wide variety of lesions and primary and metastatic tumors, including those in the brain, spine, lung, pancreas, liver, kidney and prostate.
In general, CyberKnife reimbursement exists in the U.S. and other countries for standard applications of stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) by both Medicare and commercial payers. Brain, spine and lung cancers are the most commonly covered types of cancer across all payers. Reimbursement typically aligns with evidence-based standards of care based on hundreds of published studies over the last decade to validate clinical effectiveness, reductions in treatment related side-effects, and improvements in patients' quality of life. In the U.S., CyberKnife treatment is supported by the leading professional society for radiation oncology, the American Society for Radiation Oncology, and is included as a treatment option in treatment guidelines developed by the National Comprehensive Cancer Network and the National Cancer Institute.
Why would CyberKnife treatment for a tumor not be covered by insurance?
Physicians continue to study new applications for the CyberKnife System either as a stand-alone therapy or in combination with other treatments to determine how it can be used most effectively.
Because every patient is unique, CyberKnife may be appropriate in the treatment of less common indications or when an unusual aspect of a tumor, tumor location or overall health status may preclude other treatments. In cases where insurance coverage is not available but the physician and patient think that the CyberKnife System may be the best option, an insurance appeal may be necessary.
Cost and Reimbursement
The center you have selected for your treatment has the best information on cost of treatment, reimbursement coverage for your particular condition, the process for approval and the amount of your out-of-pocket expense for co-pays.
Prior to starting CyberKnife treatment, the doctor or reimbursement administrator will investigate whether treatment is covered.
If the patient is covered by a private payer or Medicare Advantage plan, the center may seek a prior authorization.
If the patient is covered by traditional Medicare Parts A or B, prior authorization is not required and coverage is generally provided for a broader range of indications; nonetheless, treatment usually follows guidelines or a published coverage policy found on the Medicare Administrative Contractor website.
If no policy exists or the policy has been retired, the center may make treatment decisions based on medical necessity.
During this part of the process, the patient's role is minimal. If the center determines the patient is eligible for coverage, the center will contact him or her for scheduling to initiate treatment.
If your insurance carrier is not one with which the center is familiar, you may be asked to contact your carrier directly to assess whether your condition is covered for CyberKnife treatment.
If the CyberKnife treatment is denied, the doctor will typically engage in a peer-to-peer conversation or draft a letter to the payer, which describes why the CyberKnife treatment is appropriate and medically necessary in your specific case. The payer may review the letter and decide to authorize payment for the CyberKnife treatment, informing the doctor’s office or reimbursement administrator of the approval. Or, the payer could again deny eligibility, after which the patient will have the right to appeal the decision.
The Right to Appeal
If a payer still denies coverage for the CyberKnife treatment, the patient will have the right to appeal. Coverage is sometimes denied because payer policies have not kept pace with medical practice, or the payer does not understand the therapy or its application and benefit in your case. Therefore, providing comprehensive information to them can be very helpful. You should check your policy to better understand the appeal process.
Often insurers offer two rounds of internal appeals and then the right to an external appeal. Medicare and many other payers have contracts with independent companies to assist in resolving disputes. You can find additional information on the Medicare appeal process at www.medicareappeal.com.
Your Role in the Appeal
Your role in the appeal is critical because insurers expect to hear from the patient themselves. Clarify with your center whether you will need to shepherd the appeal or not.
Keys to a Successful Appeal
The appeal process is designed to ensure that all critical decisions affecting your care – including whether you receive CyberKnife treatment – is given the consideration it deserves. There are five steps that can be taken to give you the best chance to overturn a denial:
Understand the Payer’s Reason for Denial – Understanding the payer’s reasoning for denial is very important because it will help you and your doctor develop an appropriate approach for a successful appeal and gather the necessary supporting documentation. In cases where coverage is still denied, their letter of denial may give one or more of the following reasons why the payer will not cover your CyberKnife treatment, such as:
- The treatment is investigational or experimental
- The treatment is not medically necessary
- The treatment is not the standard of care
Appeal in writing – You must send a letter to the payer requesting that the coverage decision be reversed. The letter should be written within the deadline mentioned in the denial notice, typically within one to four weeks, and it should contain relevant information about you, your condition and the CyberKnife treatment.
Get your doctor involved – You can ask your doctor to call the payer or send a second letter seeking reconsideration of the denial. Sometimes there will be a faster response when a doctor personally calls the medical director of the insurance plan. Also, the doctor can send a formal letter requesting coverage approval and submit supporting documentation on the medical necessity of the treatment. The letter should contain information that may not have been included in your letter, such as medical details and clinical efficacy of the CyberKnife treatment.
Be persistent – You should be persistent and follow-up with the doctor, reimbursement administrator and payer staff on all correspondence and progress. Often, the doctor’s staff is willing to help, but it is important for you to be in charge of the process and take responsibility to keep it moving along.
Keep good records – You should maintain proper records and documentation, and ask the doctor for copies of any correspondence that he or the office staff presented to the payer. You also should keep track of each contact you make with the doctor, office staff and payer. It’s important to note the date, contact person and nature of the discussion. This will help you keep track of the details involved with the interactions, such as requests, follow-ups and promises with all parties.