CIGNA & BC/BS adds electron IORT single-treatment APBI

February 28, 2018

Coverage Update:  Over 40 million more patients in and across the US have increased access to electron-based IORT for low risk breast cancer

Throughout 2017, based on the growing body of evidence and the updated ASTRO Consensus Statement on APBI, affirming the efficacy of single-treatment electron IORT, many private insurance carriers have updated their medical policies to include electron-beam IORT as medically necessary for low risk breast cancer patients. EviCore Healthcare, a leading third party benefit manager, is the latest to do so, enabling 40 million patients greater access to single treatment IORT.

Many major healthcare insurance companies reference the EviCore Radiation Therapy Clinical Guidelines including:

  • Health Care Service Corp/Blue Cross Blue Shield (IL, MT, NM, OK, TX): 15 million insured
  • CIGNA: 14 million insured
  • Health Net (AZ, CA, OR, WA): 4 million insured
  • Blue Cross Blue Shield Alabama: 3 million insured
  • Emblem Health/GHI/HIP (NY, NJ, DE, VT): 2.5  million insured
  • Independence Blue Cross (Philadelphia & Southern Pennsylvania): 2.0 million insured

Per the updated guidelines which are scheduled to be effective on April 1, 2018:.

The use of single fraction IORT at the time of breast conserving surgery will be considered for select node-negative individuals with invasive cancer in accordance with ASTRO guidelines (Correa et al., 2017)

A. Electron-beam IORT is considered medically necessary in a node-negative individual 50 years of age or older with invasive cancer and negative surgical margins

B. Consideration will be given for low-energy x-ray IORT (INTRABEAM®) when limited to a node-negative individual 50 years of age or older with invasive cancer and negative surgical margins who is enrolled in a prospective clinical trial or registry.  However, coverage is dependent on the member’s policy language as it relates to clinical trials and registries.

The use of electronic brachytherapy (XOFT® Axxent®) for IORT is considered experimental, investigational and/or unproven.

EviCore Updated Policy

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 8,000 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.