Comparison of Local Medicare Guidance and Medicare Advantage Plans for Stereotactic Radiosurgery for Brain Metastases.

PURPOSE: Medicare Advantage operates under a capitated payment model, where Medicare Advantage Organizations (MAOs) must provide services that meet or exceed Medicare Parts A and B standards, ensuring actuarial equivalence. MAOs are mandated to base their coverage determinations on medical necessity, aligning with Medicare's national and local coverage determinations (LCD) policies. METHODS AND MATERIALS: This study evaluates coverage policies for stereotactic radiosurgery (SRS) for brain metastases (BM) across our institution's local LCD and various MAOs, including Cigna, Aetna, UnitedHealthcare, Humana, and Anthem. The CMS LCD L39553 (CMS) serves as the benchmark, deeming SRS medically necessary for new BM and repeat BM therapy if the patient has each of the following: good performance status (Karnofsky Performance Status ≥70 or Eastern Cooperative Oncology Group Performance Status 0-2), absence of leptomeningeal metastases, and no primary diagnosis of lymphoma, germ cell tumor, or small cell carcinoma. For repeat BM, CMS also requires stable extracranial disease and a life expectancy over 6 months. Additionally, SRS may be indicated for relapses in previously irradiated cranial fields to minimize normal tissue injury. Five MAO policies were reviewed, revealing alignment with LCD criteria in several areas but also presenting additional, sometimes more restrictive, requirements. RESULTS: For new BM, all MAOs required good performance status, with most also considering histology and absence of leptomeningeal metastases. Some MAOs introduced criteria like systemic therapy options, lesion number/volume, and BM size. For repeat BM, most MAOs required stable extracranial disease and occasionally considered life expectancy. Additional criteria included the number of BM over a year and postoperative SRS guidelines for lesion size and number. CONCLUSIONS: Despite general concordance, the added criteria by MAOs could impose more stringent requirements than CMS, potentially resulting in coverage denials. It is important that MAO policies remain consistent with evidence-based guidelines to avoid disparities that could impact patient treatments.

Duke Scholars

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