Understanding insurance coverage for SIR-Spheres

When thinking through your treatment options for metastatic colorectal cancer (mCRC), insurance eligibility can be a huge concern. This blog breaks down the ins and outs of insurance procedures related to the use of SIR-Spheres® Y-90 resin microspheres also known as Selective Internal Radiation Therapy (SIRT) or Radioembolization – a treatment option for inoperable liver tumors.

The Treatment

SIR-Spheres® Y-90 resin microspheres are used for the treatment of colorectal cancer that has spread to the liver (mCRC) and resulted in liver metastases that cannot be surgically removed. SIRT delivers millions of tiny radioactive beads (SIR-Spheres® Y-90 resin microspheres) directly to the liver tumors. Performed by an interventional radiologist who is trained to deliver targeted treatments involving the use of a catheter through an artery, SIRT offers a minimally-invasive treatment option for patients. 

Getting Covered

If you are approved as a candidate by your doctor (typically your regular medical oncologist), you will then see a interventional radiologist who will contact the your insurance to understand your specific benefit plan for coverage.

The Interventi0nal Radiologist’s office will submit a pre-approval request to your insurance company. This pre-approval covers all work-up related to the SIR-Spheres® Y-90 resin microspheres treatment, including a study (called a diagnostic angiogram) to understand the blood supply to the liver tumor (mapping  procedure) and 1-2 SIRT treatment procedures, depending on your Interventional  Radiologist’s recommendation. In addition, insurance policies are generally structured to cover follow-up appointments with the Interventional Radiologist before you return to your ongoing treatment plan from your regular doctor.

After all costs (patient co-pays and out-of-pocket) amounts are determined and approval is received from the insurance company, the Interventional Radiologist’s office will then contact you to schedule the necessary appointments. The majority of the procedures are performed on an outpatient basis, meaning you can go to the hospital in the morning to have the procedure and return home four to six hours after the treatment. 

The majority of private insurance companies provide coverage for the SIRT treatment for inoperable, or unresectable, colorectal liver metastases, provided you have completed first line chemotherapy (which usually includes six rounds of chemotherapy). If you have not completed first line treatment this can be a potential challenge to securing insurance pre-approval. While this circumstance may occur on occasion, the situation can often be successfully overturned on an appeal.

For the most part, insurance companies will grant approval for the SIRT procedures if you are receiving second or third line chemotherapy and have proven progression of your disease and related symptoms of your liver tumors on imaging reports.

In the unlikely event that a denial is received, you have the right to appeal the insurance company’s decision with the help of your Interventional Radiologist. In most cases, the majority of appeals will be won due to the abundance of clinical evidence that supports the use of SIRT for patients with inoperable liver tumors.¹ It’s important to note that getting turned down, even at first-line, doesn’t mean that your approval won’t be granted – 98%of appeals² submitted by Interventional Radiologists, on behalf of their patients, are eventually approved. On average, authorization for approval takes 5-7 business days.

Any responsibility of cost to you will depend on your insurance policy and detailed benefit coverage. These costs will be discussed with you prior to the treatment. For more precise issues related to billing and cost financing, you should contact your physicians directly to discuss insurance policy and provider (physician and hospital) particulars to calculate anticipated out-of-pocket costs.

Medicare provides coverage for SIRT for metastatic colorectal cancer. Traditional Medicare plans pay 80%of the cost of the procedure in the outpatient hospital setting. If you have a supplemental plan, then the remaining 20%will be covered by the secondary plan. For the most part, Medicare Advantage plans cover the majority of the costs once your deductible is met. Your Interventional Radiologist’s office will be able to provide an accurate picture of expected costs related to the hospital and other factors.

Before beginning the treatment process, you should fully understand the potential side effects of SIRT. Although the reported side effects are usually mild, all patients are unique and should be aware of, and take precautions as outlined by their treatment team.

It is also essential for patients to discuss the possible benefits and risk of treatment with their physicians to assess realistic outcomes from the procedure. Furthermore, patients and their referring physicians should recognize that imaging performed immediately post-treatment will not provide an accurate assessment of the patient’s response to SIRT. The internal radiation treatment causes swelling of the tumor area treated and on imaging the area will appear larger. Therefore, the physician should follow the patient’s tumor markers (such as CEA -Carcinoembryonic Antigen) for the first 4-6 weeks and schedule re-staging imaging three months after the procedure.

To find an interventional radiologist who can perform the SIR-Spheres® Y-90 resin microspheres procedure, visit the Treatment Center Locator tool for a nearby facility.

REFERENCES

¹ Colorectal Cancer (2014) 3(4), 331-344. SIR-Spheres Radioembolization in the management of colorectal cancer:  a medical oncology perspective Marwan Fakih.

²Sirtex internal predetermination program metrics – data on file.