Does Medicare cover proton beam radiation therapy

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imtls
Regular Member


Date Joined Oct 2011
Total Posts : 25
   Posted 1/23/2013 12:43 AM (GMT -6)   
I am turning 65 years old at the end of January, 2013. I can enroll in Medicare Part A, Part B and Part D right now. I am currently in the middle of my initial enrollment period which ends in April, 2013.

My question:
Does anyone know if Medicare is approving or rejecting Medicare members in their efforts to receive proton beam radiation (PBRT)?

I talked to a Medicare representative over the telephone today and she said “Proton Beam Therapy is not something typically covered”. The representative did not say Proton Beam Therapy is not covered.

I talked to an MD Anderson representative over the telephone today and she said “Medicare has been paying for Proton Beam Therapy at MD Anderson”.

I would appreciate finding out if you or anyone you know has been approved for proton beam therapy by Medicare. I would also appreciate finding out if you or anyone you know has NOT been approved for proton beam therapy by Medicare.

Thanks for any response.
Male, age 64
psa 4.34, biopsy 7/27/11 2 of 14 cores positive (5% and 20%) & 1 PIN
Gleason 3 + 3 = 6, Clinical Stage T1c
9/27/11 PCA3 score 14.0
9/28/11 biopsy 2 of 14 cores positive (5% and 20%), Gleason 3+3 = 6
10/06/11 Mayo reviewed 9/28/11 biopsy; Gleason 3+4 = 7
06/02/12 M.D. Anderson reviewed 9/28/11 biopsy; Gleason 3+3 = 6
11/09/12 Bladder tumor removed
latest PSA 3.82

hotrod58
Regular Member


Date Joined Sep 2012
Total Posts : 36
   Posted 1/23/2013 12:57 AM (GMT -6)   
Greetings:
From what I have heard, it does not cover it. In fact, have seen commercials that stated in small print, "Not Medicare approved". I understand they feel it is still considered experimental. If I am wrong, someone please correct me. Just going by what I have seen on their commercials and heard from others.

Ask the rep if they are wrong,,,will they pick up your bill in full,,,Bet that gets an answer.

Good Luck & Good Health: Hotrod

Post Edited (hotrod58) : 1/22/2013 11:00:07 PM (GMT-7)


robertC
Veteran Member


Date Joined May 2011
Total Posts : 966
   Posted 1/23/2013 8:52 AM (GMT -6)   
If proton costs 130K and Medicare covered 80%, you would still be on the hook for 26K.
The recent studies have shown no real advantage of proton over other newer radiation treatments.
Just my thoughts. Good luck to you.

Jerry_Delaware
Regular Member


Date Joined Jul 2011
Total Posts : 146
   Posted 1/23/2013 9:12 AM (GMT -6)   
When I had PBT in 2010, it was covered by Medicare at Florida Proton. At the time I was 62 and had Aetna, but asked the quesiton, "What would by bill be if I only had Medicare?" I wish I had remembered the answer, but I do remember that the Medicare rate was substantually less than the "list price" - and then you would pay 20% of the discounted price (assuming you don't have secondary insurance).

According to the Proton Bob site (click on #8), it is currently covered by Medicare.

...Jerry
PCa History: VIEW IMAGE

Squirm
Veteran Member


Date Joined Sep 2008
Total Posts : 691
   Posted 1/23/2013 9:19 AM (GMT -6)   
robertC said...
If proton costs 130K and Medicare covered 80%, you would still be on the hook for 26K.
The recent studies have shown no real advantage of proton over other newer radiation treatments.
Just my thoughts. Good luck to you.


I thought the studies showed no advantage in terms of efficacy, however it was more beneficial in terms of less side effects in relation to other treatment.

Water Guy
Veteran Member


Date Joined Jul 2011
Total Posts : 2403
   Posted 1/23/2013 9:27 AM (GMT -6)   
My insurance in 2011 would not have covered PBRT but medicare would have. We now have a CyberKnife clinic in my city (not in 2011) and my insurance would cover that cost. From what research I have found CyberKnife may be as effective as PBRT and a whole lot less cost and time with about the same outcomes and SE's or lack of SE's. PBRT can be a daily 6 to 8 long week treatment so you have to live near a facility. Cyberknife can be done in 5 to 7 treatments in less than 10 days.
 
 
Terry
AGE 61 Dx with fam hist of PC
PSA
1.5 5/09
2.5 6/10
3.5 12/10 ref URO
5.25 3/11 DRE Neg
BX 4/13/11 2 of 12 cores diag both sides 15% & 20% GS7(3+4)
RALP nerve-sparing 6/8/11 path G7 pT2C, Marg-Lymph-Sem-Vas-PNI- organ confined 60% tumor involved 69grms 4.3X4X3 cm
100% dry 7/3/11
post PSA
9/11 <0.07
12/11 <0.04
3/12 <0.01
6/11/12 <0.01
9/26/12 <0.001
TRIMIX injections for 100% ED

Post Edited (Water Guy) : 1/25/2013 5:16:31 AM (GMT-7)


Buddy Blank
Veteran Member


Date Joined Jan 2013
Total Posts : 1024
   Posted 1/23/2013 2:47 PM (GMT -6)   
Saw a Medscape article today and remembered this thread. The article indicates that Medicare will pay for it.

"Median Medicare reimbursement was $32,428 for PRT and $18,575 for IMRT."www.medscape.com/viewarticle/777397?src=nl_topic

imtls
Regular Member


Date Joined Oct 2011
Total Posts : 25
   Posted 1/23/2013 3:27 PM (GMT -6)   
Thank you for your replies.

I asked the MD Anderson representative what is my cost if Medicare paid 80% and I had to pay 20% out of my pocket.

She said if I had to pay the 20% not covered by Medicare, she “guessed” I would pay $8,000 to $9,000. She also provided me with a maximum figure of no more than $10,000 out of my pocket.

Using those figures means the total cost paid by Medicare (pay 80%) and by me (pay 20%) for proton beam therapy would be around $40,000 to $45,000 with a maximum of $50,000.

I can easily see where the Median Medicare reimbursement (the 80% they pay) could be $32,428.

If Medicare's 80% was $32,428 and I had to pay the other 20%, I would have to pay $8,107. The total cost for proton beam therapy in this situation is: $32,428 + $8,107 = $40,535.

I have talked to a number of proton beam therapy patients and they are the only prostate cancer patients telling me I can receive proton therapy every morning (Monday thru Friday) and I can play golf every afternoon.

Since I am sitting in Minnesota right now with an outdoor temperature of 5 below zero heading for 15 below zero tonight, playing golf in the afternoon in Houston, Texas sounds pretty good to me.
Male, age 64
psa 4.34, biopsy 7/27/11 2 of 14 cores positive (5% and 20%) & 1 PIN
Gleason 3 + 3 = 6, Clinical Stage T1c
9/27/11 PCA3 score 14.0
9/28/11 biopsy 2 of 14 cores positive (5% and 20%), Gleason 3+3 = 6
10/06/11 Mayo reviewed 9/28/11 biopsy; Gleason 3+4 = 7
06/02/12 M.D. Anderson reviewed 9/28/11 biopsy; Gleason 3+3 = 6
11/09/12 Bladder tumor removed
latest PSA 3.82

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 5904
   Posted 1/23/2013 4:05 PM (GMT -6)   
The answer is "Maybe". See:
 
 
In this doc (dated 27 Nov 2012) it cites "Proton beam therapy for prostate cancer" as "No NCD, local coverage policies in place". That means that there is no national rule, so the decision is made at the level of the CMS that approves requests for your area.
 
In effect, it could be covered in one state and not another.
Moderator - Prostate Cancer
(Not a medical professional)

DaVinci 10/2009
My adjuvant IGRT journey (2010) -
www.healingwell.com/community/default.aspx?f=35&m=1756808
HT (Lupron) 6-mo injection 9/12;Prolia 6-mo inj 12/12

stixandstonz
Regular Member


Date Joined Nov 2012
Total Posts : 91
   Posted 1/23/2013 6:04 PM (GMT -6)   
I just finished proton at UFPTI, info in the BOB meetings they have is that Medicare pays 80%. You can have treatment in the morning and golf in the afternoon. If you get the supplemental insurance your cost would be nothing for treatment, you would still have to pay for housing and food to live away from home for 8 weeks. There were half a dozen guys going through the treatment on Medicare and had supplemental insurance and had no expense for treatment. Also as a side note, if you set foot in Vietnam, you may be eligible for a Full disability from uncle sam. The weather is nice in Florida this time of year. Fill out the contact info on UFPTI's site and you will have a package overnighted via FedEx in a day or so. They include a copy of Bob Marckini's book "You Can Beat Prostate Cancer And You Don't Need Surgery to Do It". I can't say enough about how Wonderful they are at UFPTI. Good Luck with your decision.
Regards,
Kris
Diagnosed at 51, 7/12 PSA 4.0, DRE negative.
Gleason 8, 3 of 12 cores positive. Left Apex GS 4+3=7 10% of specimen, Left Mid GS 4+4=8 10% of specimen, Left Lateral Apex GS 3+4=7 60% of specimen. 3 of 12 cores positive.
CT w/contrast & bone scans negative.
Decided on ADT w/Proton Therapy at UFPTI 8/12
Trelstar 11.25 mg shot, ADT 8/12 and 11/12
Proton treatment finished 1/13, no incontinence or ED

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 2350
   Posted 1/23/2013 8:32 PM (GMT -6)   
It all happens backstage...If the proton provider agrees to accept Medicares flat rate payment for prostate radiation, then they will pay for it....They might tell you it's $200K for proton, but they will accept Medicares $100K payment if their proton machine has many open appointment slots to fill....They have to pay the operating crew whether they treat you or not so if they are not too busy, yes, Medicare will pay for it..If the machine is booked up with full-price customers, you are out of luck, they will refuse the Medicare payment unless you agree to make up the difference, which might not be legal..If they agree to accept the medicare payment, they can't (legally) come after you for more....(I think, could be wrong..)

And you better find out if you doctor and urologist accept new Medicare patients..You may end up in a Medicare Advantage program just to get in the door...
Age 70
PSA age 55: 3.5, DRE normal.
age 58: 4.5
61: 5.2
64: 7.5,
65: 8.5, " normal", biopsy, 12 core, negative...
66 9.0 "normal", 2ed biopsy, negative, BPH, Proscar
67 4.5 DRE "normal"
68 7.0 3rd biopsy positive, 4 out of 12, G-6,7, 9
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT. 2-15-'11 PSA <0.1 10/'11, <0.1 2/12, <0.1, 4/12 <0.1, 9/12, 0.8

Post Edited (Fairwind) : 1/23/2013 6:35:40 PM (GMT-7)


imtls
Regular Member


Date Joined Oct 2011
Total Posts : 25
   Posted 1/24/2013 12:12 AM (GMT -6)   
Again, thanks for all of your responses.

This information is very valuable to me.

Sometimes it feels like you are all alone in dealing with prostate cancer issues.

As I mentioned before the MD Anderson representative did tell me Medicare was paying 80%.

It is good to receive links to other material to read.

It is also good to get some conformation that Medicare does not deny coverage to all prostate patients.

Best of luck to all of you.
Male, age 64
psa 4.34, biopsy 7/27/11 2 of 14 cores positive (5% and 20%) & 1 PIN
Gleason 3 + 3 = 6, Clinical Stage T1c
9/27/11 PCA3 score 14.0
9/28/11 biopsy 2 of 14 cores positive (5% and 20%), Gleason 3+3 = 6
10/06/11 Mayo reviewed 9/28/11 biopsy; Gleason 3+4 = 7
06/02/12 M.D. Anderson reviewed 9/28/11 biopsy; Gleason 3+3 = 6
11/09/12 Bladder tumor removed
latest PSA 3.82

cbk406
New Member


Date Joined Jul 2012
Total Posts : 1
   Posted 1/24/2013 8:24 PM (GMT -6)   
I was treated with PBT at Loma Linda University Medical Center from August to October of 2012 and many of the patients treated there at that time were covered by medicare.
I highly recommend PBT. I have absolutely no side effects from the treatment. I have friends that had surgery and seeds and they all had complications. Although there are many reports that PBT (proton beam therapy) is no better than X-ray, regular or photon radiation, I believe that all those papers are flawed. True--all treatments are about equal in getting rid of prostate cancer, but if you look at what patients have to say, PBT is head and shoulders above any other treatment when it comes to not having incontinence or impotence or other side effects. What really made up my mind was reading the hundreds of stories about men who had gone through all varieties of treatment for prostate cancer on websites such as this one: http://www.yananow.org/Experiences.html
Also, I recommend http://www.protonbob.com/proton-treatment-homepage.asp
Best Regards,
Gary

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 5904
   Posted 1/24/2013 11:02 PM (GMT -6)   
cbk406,
 
Welcome to HW. I will need to say here that we don't allow links on a first post, as they are most often spam. Because I recognize the sites you mention, I'm going to leave them.
 
We suggest that you create a new thread introducing yourself so that the members will have a chance to welcome them.
 
I considered PBT (at a distant MD Anderson facility) as a treatment, but my insurance would not allow it, as they considered IGRT (available in my area) as equal in results. Lots of decisions here are tempered (or tainted, as it were) by our individual financial resources.
Moderator - Prostate Cancer
(Not a medical professional)

DaVinci 10/2009
My adjuvant IGRT journey (2010) -
www.healingwell.com/community/default.aspx?f=35&m=1756808
HT (Lupron) 6-mo injection 9/12;Prolia 6-mo inj 12/12
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