The CyberKnife® Robotic Radiosurgery System was cleared by the U.S. Food and Drug Administration (FDA) in August 2001 to treat tumors anywhere in the body. Now the CyberKnife System, which delivers radiation with extreme precision, is being used around the world to treat a wide variety of tumors, including those in the head and neck, spine, lung, pancreas, liver, kidney and prostate.
CyberKnife treatments have demonstrated promising results, with over 700 clinical and technical articles published as of December 2012. Additionally major medical conferences worldwide have featured presentations on the clinical effectiveness of CyberKnife System for both intracranial and extracranial tumors, and how CyberKnife treatments minimize side effects to preserve a patient's quality of life.
To find out if CyberKnife treatment is appropriate for you, contact a CyberKnife facility in your area. CyberKnife center locations can be found on the Accuray website at www.accuray.com by clicking on the "TREATMENT CENTERS" tab.
Understanding the process:
Prior to starting CyberKnife treatment, the doctor or reimbursement administrator will request authorization for the treatment from your payer (private insurance or Medicare intermediary). During this initial authorization process, your role is minimal. However, if the CyberKnife treatment is denied, your involvement will become instrumental. At this point, the doctor will typically 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 your eligibility, after which you have the right to appeal the decision.
While navigating the reimbursement process can be confusing, working with the appropriate people and gathering the right information can make it easier. Here are some tips on who, and what, you should know as you begin seeking coverage for your treatment:
- Know your healthcare insurance benefit plan administrator – Contact the provider of your group health insurance to find the administrator and ask if your specific plan includes coverage for radiosurgery treatment.
- Contact the medical facility's reimbursement administrator assigned to your case – This person can advise you on how long it should take to secure the prior authorization for CyberKnife treatment and be the point of contact for checking the status of your treatment approval. If your request is denied, this person can intervene on your behalf with the payer to explain your specific need for the treatment.
In some cases, authorization of CyberKnife treatments may be denied because the payer does not have enough information to make a favorable coverage decision. Their letter of denial may give one or more of the following reasons why the payer will not cover your CyberKnife treatment:
- The treatment is investigational or experimental.
- The treatment is not medically necessary.
- The treatment is not the standard of care.
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.
The Right to Appeal
If a payer denies coverage for the CyberKnife treatment, you have the right to appeal. Coverage is sometimes denied because the payer does not understand the therapy. Therefore, providing comprehensive information to them can be very helpful. You should check your policy to better understand the appeal process.
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 four steps that can be taken to give you the best chance to overturn a denial:
- Patient appeal in writing - You can 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.
- Doctor involvement – 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.
- Persistence pays – 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. Remember, this can be a time-consuming process and the doctors, nurses and others are working with many other patients at the same time, and the paperwork can easily get overlooked.
- 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.
If you've unsuccessfully exhausted the appeal process, there are other resources to consider:
External Review Process - 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. If you have commercial or private insurance (not Medicare), the denial may not be automatically forwarded to an independent dispute resolution company. If dispute resolution services are available, you or your doctor can request a review. You can contact the payer for more information on the external review process or services.
Employer group assistance - Employers that provide benefits to their employees through non-Medicare payers can often request that "an exception to benefits" be made to allow coverage for CyberKnife treatments. The human resources department can assist in explaining benefit information and provide contact information.
Legal assistance – Contact your state insurance board or attorneys that specialize in healthcare. You also may be able to find other services available in your state.
Patient Advocacy Organizations – There are many patient advocacy organizations that offer financial and or legal assistance. These websites are good examples of resources that are available on the Internet: