Medicare Compliance & Reimbursement

APBI policies follow physician society's recommendation.

A new technology is revolutionizing breast cancer treatment - but for now, carriers are lining up to put severe limits on it.
 
Draft local coverage determinations from National Heritage Insurance Co. and Arkansas Medicare are putting sharp limits on coverage for accelerated partial breast irradiation, a new technique.
 
Unlike whole-breast external-beam radiation therapy, ABPI targets only a segment of the breast after a lumpectomy. Also, radiation is delivered over four to five days instead of over five to six weeks, at higher doses per session. APBI includes brachytherapy via catheter, the MammoSite radiation treatment system, accelerated external beam radiotherapy and intra-operative radiotherapy.
 
APBI should present less risk to healthy breast tissue than WB-EBRT because it's more carefully targeted, say the carriers.
 
But the carriers both set important limits on APBI therapy, until they receive more clinical data on its effectiveness. For now, patients must be 50 years old or older, with a diagnosis of invasive ductal carcinoma. The tumor must be 2 centimeters in diameter or less, and the nodal status must be negative based on "axillary lymph node dissection or sentinel lymph node evaluation." Additionally, for NHIC but not for Arkansas, the margin status must also be negative.
 
These criteria are exactly the ones recommended in April 2003 in a consensus statement by the American Society of Breast Surgeons. The ASBS said the published data was neither "extensive nor definitive" for APBI, and it should be used either in the circumstances the carriers have just proposed, or in clinical trials and institutional protocols. Surgeons and oncologists using the various APBI techniques should be "adequately trained to allow for optimum radiation therapy planning and treatment."
 
The surgeons excluded lobular carcinoma because "they have a higher propensity to multicentricity." And they chose 2 cm as the maximum size "because the vast majority of studies had an average tumor size less than 2 cm." Margins should be negative because APBI "is not a technique to 'clean up' positive margins," adds surgeon Peter Beitsch. Also, the patients should have negative lymph nodes because otherwise the patients might have tumor cells in the lymphatics of the breast that wouldn't be treated by partial irradiation.