Renee* is a 47-year-old office manager and married mother of two. She has a history of stage 1 non-small cell lung cancer and epilepsy.
Eighteen months after lung surgery to treat her cancer, Renee experiences a persistent cough.
Renee’s oncologist orders a PET/CT scan.
Diagnosing Renee
While awaiting the lung panel results, Renee’s oncology team recommends starting stereotactic body radiation therapy (SBRT) to treat her liver cancer and intensity modulated radiation therapy (IMRT) to treat her lung cancer recurrence.
Treating Renee – Radiation
Renee’s lab panel confirms a new mutation in her lung cancer. She undergoes successful radiation and chemotherapy. Renee’s oncologist requests further therapy with combination Tarceva® (erlotinib) and Keytruda® (pembrolizumab).
Treating Renee – Chemotherapy
Renee avoids the clinical side effects and unnecessary costs associated with Keytruda treatment.
Avoiding Unnecessary Care & Costs
Achieving Better Outcomes
Renee’s CT scan shows a suspected cancer recurrence in the opposite lung and suspicious mass in the liver. A subsequent biopsy confirms the cancer has spread to her liver. Her oncologist orders a comprehensive genomic biomarker panel using multiple CPT codes.
Pinpointing Renee's Cancer
EviCore determines a PET/CT scan is not the most appropriate test for her at this point in her treatment and recommends a more evidence-based lung CT scan with contrast. This is a simpler, shorter, more focused procedure with less radiation exposure and lower out-of-pocket costs. Also, 10%-30% of PET scans can be falsely positive for benign lesions, resulting in unnecessary biopsies to rule out cancer.
Using multiple CPT codes would increase costs for Renee and her health plan. Instead, EviCore recommends using a single panel code, in accordance with AMA coding guidance. The lab performs the same test at a much lower cost for Renee and her plan.
An EviCore board-certified radiation oncologist reviews Renee’s case, approves SBRT, and consults with her physician who agrees to use 3D conformal, a radiation therapy with equivalent outcomes as IMRT for this tumor type at lower cost for Renee and her plan.
EviCore’s oncologists determine Keytruda is clinically inappropriate for Renee’s case due to significant negative side effects and insufficient evidence to support any benefit. After a collaborative discussion, Renee’s oncologist agrees to prescribe oral Tarceva alone as per national evidence-based guidelines.
Renee’s oncology team experiences a much simpler medical and pharmacy benefit authorization process.
Her health plan avoids $120K+ in unnecessary drug costs.
If her plan was using different vendors to manage medical and pharmacy benefits, they may have approved Tarceva and Keytruda separately, leading to an expensive and poor outcome for Renee.
There are many different facets to cancer care, which can create fragmentation. Achieving the best outcomes takes advanced, efficient coordination – from radiology and lab testing to medication regimen selection and care delivery.
EviCore’s comprehensive oncology solution works together with providers and payers to support the latest evidence-based care for patients throughout their journey.
Learn more at evicore.com
What happens next?
Are both needed?
What about the provider and plan?
Is there a better option?
Radiology
EviCore ensures advanced imaging services are in accordance with the most up-to-date literature and national guidelines to promote the most clinically appropriate and cost-effective care.
We safeguard patients and payers by authorizing only genomic, molecular, and
non-molecular tests that meet evidence-based care criteria and coding guidelines.
Laboratory Management
EviCore uses the latest evidence-based clinical guidelines from peer-reviewed literature, professional societies, and leading cancer physician experts to help patients achieve optimal outcomes.
Radiation Oncology
Medical Oncology
Reducing inappropriate prescribing is the most powerful lever for managing rising drug spend. We guide providers to National Comprehensive Cancer Network recommended treatment plans for each unique patient, decreasing administrative time and improving outcomes.
*Not patient’s real name. Images are for illustration purposes only.
Is it necessary?
Meet Renee
