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Does Medicare cover Proton Beam Radiation Therapy?
I have also posted this information on the Us Too prostate cancer web site>
I have heard both Medicare does NOT cover Proton Beam Radiation Therapy (PBRT) and Medicare does cover PBRT.
The Centers for Medicare & Medicine Services (CMS) website has this to say about PBRT:
Proton beam therapy for prostate cancer: No National Coverage Determination NCD, local coverage policies in place.
I live in Minnesota. I visited the WPS.Medicare website and navigated to the where I could find the local coverage policies for Minnesota providers.
I found a table of Local Coverage Determinations (LCD) where it said Proton Beam Therapy had a status of “Active”, original effective date of 03/17/12 and last revision date of 12/01/12. I interpreted “Active” to mean “Covered by Medicare”.
However, the phrase “Proton Beam Therapy” is different than the phrase I would like to see “Proton Beam Therapy for prostate cancer”.
Somewhere on the site I found an area called “Revised Policies” (effective 01/01/13) and within this area I saw the following comment about proton beam therapy.
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10. Comment
In reference to Proton Beam Therapy, Indications should be limited to what is our current clinical experience. Also it should be limited to certain primary tumors and in certain situations may be metastatic lesions with clear documentation why proton beam is being used. The use of proton beam should be heavy on the pediatric patient population. Published literature should be studied very carefully by a task force before adopting every single published paper. We as radiation oncologists have a fiscal responsibility and if we are not careful Proton Beam use is going to be very difficult to sustain at the current levels, then at that point everybody will be hurt. There is no difference in the radiation biology of photons and proton beams. The difference is in the physics; Bragg-Peak and lateral scatter.
Response
We did form a task force perform further work on the document which has resulted in a better document,
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I don't know where this "better document resides".
Comment 10 made me wonder if PBRT for prostate cancer would be covered.
I welcome your comments and experiences on this topic.
I would greatly appreciate hearing from those who did receive Medicare coverage for PBRT and also from those who were DENIED Medicare coverage for PBRT.
Re: Does Medicare cover Proton Beam Radiation Therapy?
Terry,
I had proton beam therapy (PBT) in Oct 2011 at UFPTI. Medicare along with my Medicare supplement (Aetna) covered the 100% of the cost. If you contact the center where you want to have the procedure, they will put you in contact with their "insurance person" who will let you know what is covered and what your costs muight be. When I was down there at UFPTI, a couple of guys had a $30 co-pay required by their medicare supplement. Since each of the 39 "treatments" required a co-pay, they were required to pay money up front and each day's co-pay was subtracted from it. I'll bet 9wks in Florida would sound pretty nice to you guys in Minnesota about now....
Re: Does Medicare cover Proton Beam Radiation Therapy?
Terry,
I don't know the answer, which I think is "some do:some don't" but if you go the the RESOURCES page you will see a link to a site Fight Your Health Insurer and Win where you should get some current advice.
Re: Does Medicare cover Proton Beam Radiation Therapy?
Terry, while I'm not of Medicare age, I had PBRT for Gleason 6 PCa at MD Anderson in Houston, and MANY of the men taking the treatment journey with me were there courtesy of Medicare and their Medicare supplement. I agree with the advice to contact your preferred treatment center directly, which will put you in touch with their insurance folks. They'll be able to give you a straight answer based upon the coverage you have.
One cautionary note: There's no doubt that despite excellent outcomes, PBRT for PCa is under assault by many in the health policy and oncology communities. They don't argue treatment safety and efficacy, but rather its cost, which is higher than for IMRT (i.e., photons). What they woefully fail to consider is TOTAL COST over the LONG RUN, since the majority of such critiques look narrowly at the comparison with IMRT and, in some cases, with bracytherapy. What's not in dispute is that with PBRT, the body receives a significantly lower integral dose of radiation, since the radiation can be precisely targeted to the gland (versus spread diffusely as with the other modes).
I remain pleased with my results and staunchly defend the total value, over time, delivered by PBRT. I would do it all over again. However, given the irrationality and inefficiencies seeping into U.S. healthcare as a result of Obamacare, I would not be surprised if short-term thinking spelled the demise of coverage for PBRT under Medicare. Let's hope that doesn't happen.
Re: Does Medicare cover Proton Beam Radiation Therapy?
Aloha R Scott,
It appears that you are repeating what you were told by the proton advocates and that is exactly what is in dispute in the saga of EBRT Vs. Protons. Both are radiation & both deliver a dose to the body. Where & how much that dose is depends on the doc prescribing the dose and those doc's do make mistakes (as in my case). The only difference between the two treatments is cost, and the Proton sellers make a bundle of cash. If a man is sold on proton treatment, he should be allowed to pay for it out of his pocket, not ours.
Joe
Re: Does Medicare cover Proton Beam Radiation Therapy?
Please do not start an argument for and against Proton Beam Therapy.
There can be no resolution to such arguments which tend to inflame men with very strong views one way or the other.
The fact of the matter is that there are no good, independent studies that demonstrate the superiority of Proton Beam Therapy. It may be better, it may have fewer side effects, but all evidence is anecdotal and not supported by good studies.
I will close down this thread if the argument continues, although posts answering Terry's original question about coverage will be welcomed.
Re: Does Medicare cover Proton Beam Radiation Therapy?
Terry:
Joe H's response appears to be "right on".
As part of your research effort I suggest you Google UFPTI then click on:
"University of Florida Proton Therapy Institute response to prostate cancer treatment comparison published Dec. 13, 2012 in the Journal of the National Cancer Institute" in the right hand column.
