CurrentKaiser PermanentePolicy No.01-18

Radiation therapy facility and hardship exception criteria

Defines where Kaiser Permanente Georgia members must receive radiation treatment (core facilities) and the conditions under which exceptions for medical hardship and alternate facilities may be considered; affects radiation oncology providers and utilization management reviewers in Kaiser Permanente Georgia.

Policy Summary

PayerKaiser Permanente

PolicyRadiation therapy facility and hardship exception criteria

Policy CodePolicy No.01-18

Change TypeReviewed/Revised

Effective DateSep 15, 2008

Next Review Date

Key ActionSubmit hardship requests from the Internal Radiation Oncologist for review and approval by the Lead Physician for Radiation Oncology.

SourceLink

POLICY UPDATE CHANGES

No material clinical or coverage changes in this revision.

3named core radiation facilities

40distance threshold (miles)

20-60 minfrailty car-ride tolerance

30/30CMS comparator limits

Coverage and Exception Criteria

Coverage and Exceptions

Covered when ALL of the following are met

Core facility requirement: Radiation therapy is to be provided at core facilities: Emory St. Josephs Hospital or Emory Midtown Hospital.

Exceptions below apply.

Inpatient initiation exception: If radiation therapy is initiated during an inpatient hospitalization at Piedmont Hospital, the patient is allowed to complete services there.

Medical hardship exception: An exception to use non-core contracted facilities may be considered when a medical hardship is present as defined by the policy and approved by the Internal Radiation Oncologist and Lead Physician for Radiation Oncology.distance > 40 miles OR inability to tolerate a 20-60 minute car ride OR inability to perform mobility-related ADLs

Policy Summary

PayerKaiser Permanente

PolicyRadiation therapy facility and hardship exception criteria

Policy CodePolicy No.01-18

Change TypeReviewed/Revised

Effective DateSep 15, 2008

Next Review Date

Key ActionSubmit hardship requests from the Internal Radiation Oncologist for review and approval by the Lead Physician for Radiation Oncology.

SourceLink

On This Page

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Judgment of MD reviewer required; requests must come from the Internal Radiation Oncologist and be reviewed by the Lead Physician for Radiation Oncology and Specialty Chief providing oversight.

Routine radiation therapy at non-core facilities is excluded unless a documented medical hardship exception is approved by the designated radiation oncology reviewers. Per policy, members are required to receive radiation treatment at the designated core facilities: Emory St. Josephs Hospital or Emory Midtown Hospital. An exception to allow treatment at a non-core contracted facility may be considered only when the medical hardship criteria are met and the exception is approved by the Internal Radiation Oncologist and Lead Physician for Radiation Oncology with oversight from the Specialty Chief.

The policy does not list additional coverage allowances beyond the exclusion described above. Determinations that services at a non-core facility are not medically necessary (or otherwise inappropriate) when a hardship has not been established are to be made by the reviewing physicians in accordance with the policy. All requests for hardship exceptions must be initiated by the Internal Radiation Oncologist and reviewed by the Lead Physician for Radiation Oncology and Specialty Chief, who apply clinical judgment when evaluating whether the medical hardship criteria are satisfied.

Coding and Thresholds

CPT/HCPCS Codes and DescriptionsCPT

No codes listed

Medical Hardship distance — Over 40 miles

Distance threshold for medical hardshipOver 40 miles

CMS comparator limits30 minutes / 30 miles

Context for exceptionException considered when travel distance (>40 miles) makes daily visits too physically demanding

Frailty travel tolerance — Cannot tolerate a car ride of 20-60 minutes

Frailty travel toleranceCannot tolerate a car ride of 20-60 minutes

Related functional limitationCannot perform any mobility-related ADLs

Reviewer judgmentFrailty-based exceptions considered at MD reviewer discretion with oversight by Lead Physician

Site Requirements and Provider Responsibilities

Prior Authorization

Site requirement and inpatient exception — Radiation therapy at core facilities

Radiation therapy must be provided at the core facilities (Emory St. Josephs Hospital or Emory Midtown Hospital).

All patients are required to receive radiation treatment at Emory St. Josephs Hospital or Emory Midtown Hospital.
Inpatient exception: Patients who have radiation therapy initiated during an inpatient hospitalization at Piedmont Hospital may complete their services at Piedmont.

Denial Risk

Denial risk for non-core facility use

Requests for radiation services at non-core facilities may be denied unless an approved medical hardship exception is granted by the MD reviewer.

Denial risk for non-core facility use unless medical hardship exception approved.

Documentation Required

Hardship exception criteria and routing

Medical hardship exceptions may be considered when travel or treatment at a core facility would cause undue suffering or cannot be physically completed by the patient.

Medical Hardship Definition: situations where receiving therapy at the core facility would cause suffering or requires special effort that cannot be physically completed.
Examples include inability to tolerate a car ride of 20–60 minutes, inability to perform mobility-related ADLs, frailty, or a considerable travel distance (over 40 miles). Note: CMS uses 30 minutes / 30 miles.
All requests for hardship radiation therapy should come from the Internal Radiation Oncologist and be reviewed by the Lead Physician for Radiation Oncology and the Specialty Chief providing oversight (currently the Associate Medical Director of Primary Care & Medical Specialties).

Step Therapy

Step therapy — Not applicable

Step therapy: Not applicable/none specified.

No step therapy requirements specified for radiation therapy.

Definitions

Medical Hardship — Definition and qualifying criteria

DefinitionA situation whereby receiving therapy at a particular location would cause suffering or requires a special effort that cannot be physically completed due to illness or frailty

Examples of qualifying conditionsInability to tolerate a 20–60 minute car ride; inability to perform mobility-related ADLs; or travel distance over 40 miles

Exception processRequests for hardship must come from the Internal Radiation Oncologist and be reviewed by the Lead Physician for Radiation Oncology and Specialty Chief

Use caseWhen daily visits to a core radiation facility are too physically demanding, an exception to use non-core contracted facilities may be considered

Background and Purpose

This policy directs members to receive radiation treatment at designated core facilities to centralize care and oversight while allowing for limited exceptions when travel or patient condition make attendance at a core facility impracticable. It recognizes that some patients may experience a medical hardship — defined as inability to tolerate travel or perform mobility-related activities of daily living, or when travel involves a considerable distance (Over 40 miles) — and permits exceptions based on the judgment of the MD reviewer. The policy also specifies that patients who begin radiation therapy as inpatients at Piedmont Hospital may complete their services there, and that Gamma Knife services are available at Emory St. Josephs Hospital. Oversight for hardship approvals is provided by the Internal Radiation Oncologist, Lead Physician for Radiation Oncology, and the Specialty Chief.