Coverage Update: Anthem Blue Cross and Blue Shield updated medical policy enables 40 Million more patients in 14 states across the US to have increased access to electron based IORT

Less than a year after ASTRO updated its Consensus Statement on APBI affirming the efficacy of single-treatment electron IORT, Anthem and several private insurance carriers have updated their medical policies to include electron-beam IORT as medically necessary for low risk breast cancer patients.

Anthem is the largest BlueCross BlueShield payer in the US with coverage for more than 40 million people in 14 states across the nation, including:

California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia, Wisconsin

According to its updated policy, Anthem Blue Cross/Blue Shield recognizes electron based IORT as medically necessary for “suitable” breast cancer patients as defined by ASTRO APBI guidelines. The policy defines the treatment as “an alternative to whole breast irradiation in the treatment of early stage breast cancer”. The current policy also recognizes electron IORT radiation therapy as medically necessary at the time of surgical excision for other cancer indications such as pancreatic, colorectal, pelvic and soft tissue sarcomas.

Per the updated guidelines on breast cancer as published on December 27, 2017:

Medically Necessary:

I. External beam intraoperative radiation therapy is considered medically necessary as the sole source of additional radiotherapy at the time of surgical excision for colorectal cancer, pancreatic cancer, pelvic cancers (for example, cervical or uterine), soft tissue sarcomas, or breast cancer when the following criteria are met:

A. Tumor cannot be completely removed; or
B. Tumor has a high risk of recurring in surrounding tissues; and
C. Intraoperative radiation therapy augments conventional external beam radiation therapy.

II. External beam intraoperative partial breast irradiation (electron or low-energy x-ray radiotherapy) is considered medically necessary as an alternative to whole breast irradiation in the treatment of early stage breast cancer when all of the following criteria are met:

A. Individual is 50 years of age or older; and
B. Clinically node negative on either preoperative physical examination (that is, non-palpable node[s]), or medical imaging if performed (for example, mammography, magnetic resonance imaging [MRI], or ultrasound); and
C. Tumor is either :

1. Invasive ductal carcinoma measuring less than or equal to 2 centimeters (T1 disease) with negative margin widths of greater than or equal to 2 millimeters, no lymphovascular space invasion, estrogen-receptor positive (ER+), and BRCA negative; or
2. Low or intermediate nuclear grade, screen-detected ductal carcinoma in situ measuring less than or equal to 2.5 centimeters with negative margin widths of greater than or equal to 3 millimeters.

The IntraOp® Mobetron® delivers a full dose of electron-beam IORT in just 2 minutes immediately following lumpectomy, making it the most cost effective APBI modality available to hospitals and their patients. The Mobetron has treated over 10,000 breast cancer patients at leading breast centers around the globe. As the world’s only self-shielded portable linear accelerator, the Mobetron can be deployed in a conventional operating room. We will show you how.

This communication is for informational purposes only. Providers should consult with their institution’s reimbursement departments and the specific patients insurance carrier for more details. Actual payment to a specific provider will vary based on several factors including the site of service, geographic location, patient population mix, and hospital teaching status. Providers must follow specific insurers’ coding and billing instructions and must report the codes that most accurately reflect the patient’s condition and the medically necessary service(s) provided. The information in this communication does not constitute legal advice. Consult with the patient’s insurer for situation-specific information.