Surviving Prostate Cancer Without Surgery

PCa Support Forum

LAC-PAACT UPDATE - 1

by Gregory H. Teufel, Esq., Chairman - 2

The following is the LAC-PAACT Update article from the September 2007 issue of Prostate Cancer Communication, the newsletter of Patient Advocates for Advanced Cancer Treatments, posted here by permission.

I am pleased to report the successful results of efforts to improve reimbursement for cryosurgery. Earlier this year, on January 25, 2007, representing PAACT, I drove to Baltimore to meet with Centers for Medicare & Medicaid Services (CMS) officials, along with representatives from other cancer victim organizations and the relevant device manufacturers to discuss the proposed payment system rates for prostate cryotherapy in the ASC (Ambulatory Surgery Center) setting.

The proposed payment formulas for prostate cryosurgery in the ASC setting, 62% of the hospital outpatient payment, made it cost prohibitive to perform prostate cryoablation anywhere other than in a hospital, limiting the range of treatment venues available for prostate cancer victims and increasing their out-of-pocket costs. We urged CMS to consider an alternative to the suggested 62% of the hospital outpatient payment because the majority (estimated to be 75%-80%) of the hospital outpatient payment for prostate cryoablation is attributed to the device and equipment, and the equipment costs remain the same whether the procedure is performed in a hospital or an ASC.

CMS listened to our recommendations and recently announced a special provision for a limited number of procedures that required a device (such as cryoablation needles) and formulated the payment rates based on a methodology that would discount the current hospital rates differently for “device intensive” procedures. The 2008 Proposed Transitional Payment has been increased from $2,809.28 to $6,201.03 and the Proposed Full Payment Rate has been increased from $4,279.56 to $6,758.75.

Gordon Woodward, also a partner in Schnader’s Litigation Services Department, previously attended a similar meeting with CMS in Washington, DC on behalf of PAACT, along with representatives from other cancer victim organizations and the relevant device manufacturers, to urge CMS to correct the hospital outpatient payment rates for prostate cryotherapy. Once again, CMS listened to our recommendations and the new proposed outpatient hospital rates increased for 2008 by 17.10% from $6,685.05 to $7,880.21. We are very pleased to report that these efforts have made this treatment more affordable and accessible for prostate cancer victims.

We are still looking for volunteers to help in the fight for approval for off-label use of drugs for prostate cancer. Volunteers have begun to step up since the last LAC-PAACT Update, but the issue is coming up more often and this is an opportunity for those inclined to make a difference.

We have had a number of inquiries from people denied coverage, either by Medicare or non-Medicare insurers, for off label use of drugs for prostate cancer. We have learned that about half of the uses of anticancer chemotherapy drugs are for indications other than those referenced in the USFDA approved label, leading to problems with coverage under Medicare, Medicaid, and private insurance. Legislation in 1993 required Medicare and Medicaid to cover medically appropriate cancer therapies including off-label uses recognized by established drug compendia and peer reviewed literature. The vast majority of states have also enacted statues requiring coverage of off-label uses of cancer drugs based on compendia.

Nevertheless, cancer victims have been plagued by inappropriate denials of coverage for off-label uses of cancer drugs, primarily because of refusal to accept peer-reviewed clinical studies as support for coverage of such uses. Timely decisions are not always made by approved compendia with respect to reviewing the available evidence and issuing conclusions about off-label uses. High quality phase II trials should also be considered as potentially providing a level of evidence sufficient to justify reimbursement. We have our work cut out for us in improving the situation, both through assisting with individual cases fighting denials of coverage and by urging coverage policy changes. If this sounds like an issue that would interest you and you want to help, please contact Greg Teufel.

We recently learned of and want to pass on information regarding low income assistance available to prostate cancer victims through a special Medicare program by calling 1-800-633-4227. Additionally, we recently were alerted to the existence of the Patient Advocate Foundation, which provides funding for those with prostate cancer, at 1-866-512-3861 (best to call in the very beginning of the month, as funds run out very quickly).

We recently received a report about a denial of coverage by a private insurer for blood tests and scans needed to (1) monitor the course of prostate cancer progression and (2) determine the total body tumor load. This is our first report of this type of coverage denial. We passed on information to help in the fight for coverage in that case and will keep you updated as we hear about the progress of that dispute. Meanwhile, if anyone has any information about similar coverage disputes in the past or going on presently, we would appreciate hearing about those as well, as we are gathering info to help fight this denial.

We want to keep you aware that the LAC-PAACT is here to help you. We are particularly helpful in addressing insurance and Medicare coverage issues related to advanced cancer treatments. Please do not hesitate to contact us regarding any coverage or other legal issues related to advanced cancer treatments. We want to help and need your help in identifying the areas of greatest need.

We are also always seeking volunteers to help with LAC-PAACT activities. Even if you are not a lawyer, you can volunteer if you are inclined to help with law related issues. Also, if you know any lawyers that would be sympathetic to our cause, please make us aware of them and them aware of LAC-PAACT. Just contact Greg Teufel regarding volunteer opportunities with LAC-PAACT.

If you have been denied coverage for an advanced cancer treatment, be sure to let us know and we will see if there is anything we can do to help.

Contact LAC-PAACT

If you have any questions or comments, or any suggestions about how LAC-PAACT can best serve your needs, please do not hesitate to contact me. The preferred method to contact me is via email at gteufel@schnader.com. You can also call me at work at (412) 577-5289, or send me a letter at Schnader Harrison Segal & Lewis LLP, Suite 2700, Fifth Avenue Place, 120 Fifth Ave., Pittsburgh, PA 15222 or a fax at (412) 765-3858. Please note that requests for the LAC-PAACT kit should be addressed to PAACT. Contact information for PAACT is on page 2 of this Newsletter. Please remember that this article is not legal advice and I cannot generally give you legal advice or become your personal attorney.

1 - LAC-PAACT is PAACT’s legal advisory committee. Despite the name of the committee, for various reasons, we generally cannot give you legal advice or act as your personal attorney. Please do not consider anything in this article as legal advice. If you want legal advice, I encourage you to consult a lawyer in your state, so that your specific situation and local laws can be considered.

2 - Gregory H. Teufel, Esq. is a partner in the Litigation Department of Schnader Harrison Segal & Lewis LLP's Pittsburgh office. The views expressed are those of Mr. Teufel personally and not of the firm.

Other newsletters are available at:

http://www.paactusa.org/newsletters/2007.html http://www.paactusa.org/

Created September 15, 2007