Y90 in the OBL: Benefits & Considerations

[Dr. Aparna Baheti]
Did anything, in particular, spur your decision to move the Y90 from the hospital to the OBL?

[Dr. Jayson Brower]
Yes, there were a couple of different things that all hit at the same time, sort of the proverbial straw that broke the camel's back. Just to touch on a couple of them, for those that are listening that are familiar with the Y90 procedure, there are really only two definitive indications; colorectal cancer and hepatocellular carcinoma. Now, like most of us, we treat a lot of things "off-label", and when we started our Y90 practice 18 years ago, we just continued on with that entrepreneurial spirit of interventional radiology, and whether it was breast cancer or melanoma or what have you, neuroendocrine, if the patient met criteria, we thought that there was a benefit of doing Y90, we would treat them.

Flash forward, I think there was a realization that perhaps there were some billing-- I'm trying to be politically correct in phrasing this, but the bottom line is, I think the hospital at one point realized that they weren't getting reimbursed on some of the cases, they missed the opportunity to file an appeal, and what they then came back to us and said was unless patients fell, and Medicare patients, in particular, unless they met criteria, either as colorectal metastases or HCC patients, they would no longer allow us to treat them with Y90 in the hospital.

[Dr. Aparna Baheti]
I see. It really limits your scope of what you can do with Y90.

[Dr. Jayson Brower]
It really does.

[Dr. Aparna Baheti]
Just on a side note, anecdotally, have you had a lot of success with the appeals for these off-label uses for Y90?

[Dr. Jayson Brower]
We have. That's the interesting thing in the OBL setting, knock on wood, we've had zero denials on any of our Y90 cases, and when you break it into--

[Dr. Aparna Baheti]
That's really interesting.

[Dr. Jayson Brower]
It all comes down to staying on top of the process and that's one of the take-home messages I would say for anybody who's considering going down this path, you really have to have good strong processes in place.

[Dr. Aparna Baheti]
Absolutely. I interrupted your story, but they weren't letting you do any off-label Y90. Anything else that really made you want to make the switch?

[Dr. Jayson Brower]
Yes. I would say there are two other main components. The nuclear medicine department in particular, while they are great, the equipment was outdated, the hospital was unable to really invest more money for state-of-the-art SPECT-CT scanning, so it presented I think, a problem when you come down to modern-day evaluation of patients, both pre and post-treatment. That was an issue.

I think finally really just patient convenience and satisfaction, and that was also a huge driving factor in moving forward with opening up the OBL. We felt we could deliver a much better product, if you will, for our patients from beginning to end.

[Dr. Aparna Baheti]
Sure. Yes, that's one of the great things about working in the OBL, is you have control over almost everything, whereas in the hospital, you'd have to interact with various administrative types and deal with staffing shortages and things that are out of your control.

[Dr. Aparna Baheti]
So you do have a cone beam CT in your OBL. That's awesome. That was really important for you when building it out probably because you were going to do Y90s there, is that right?

[Dr. Jayson Brower]
Absolutely. Not only from the Y90 standpoint, we really envision this center, and we may talk about this a little bit later, but to do all sorts of interventions. We're doing our prostates here, we're doing our UFEs here. Not that you need-- certainly for UAE, you don't need a cone bean, but for prostates, I think it's really important. When we set out to buy the equipment for this lab, it was always with the intention that it would be a full-blown interventional suite.

[Dr. Aparna Baheti]
It's nice that you had that foresight from the beginning, and you're able to plan that in rather than having to fix it afterwards. You might understand this question a little bit better than me, Jayson, but for dosimetry coding, can we get into that a little bit? Do you use the standard SIR-recommended ones or do you use dosimetry software and bill for the Rad Onc code for dose mapping?

[Dr. Jayson Brower]
I think that's a great question. It's interesting because I think as our understanding of dosimetry starts to evolve, I'll speak for our practice, we've moved past the standard BSA partition model type of approach, and we employ a software package called MIM, and the concept behind that is to really move towards something called voxel-based dosimetry.

In order to do that, you need this advanced software package. The best way I could think of describing it, it really comes down to personalized dosimetric evaluation of the patient's liver and then the blood supply not only to the normal liver but to the tumor as well. That's why I think both the cone beam is important, but the SPECT-CT, and when you start to look at how you put all these pieces together, you're now-- instead of guesstimating how much blood supply goes to the tumor or how much blood supply goes to the normal liver, you're actually measuring counts of activity within both of those structures and you get a much more personalized approach to coming up with your intended dose. It's a very long-winded way of saying we've now incorporated the software-based coding and billing into our practice.

[Dr. Aparna Baheti]
I'd love to know a little bit more about dosimetry codes for the uninitiated. Do you mind just giving a really quick overview of that?

[Dr. Jayson Brower]
Yes, and I may start to get outside of my knowledge box a little bit, but it comes down to with this MIM dosimetry and the advanced dosimetric codes, you can bill for the mapping, and then you bill for the implantation. It's a separate add-on code that you get on top of your supervision and your implantation. It's specifically for this software.

[Dr. Aparna Baheti]
That's interesting. Were the MIM software people able to help you understand the coding and billing for that stuff, or was it something that you were able to figure out on your own?

[Dr. Jayson Brower]
Yes, I would say we primarily figured it out on our own. Again, the same partner of mine who's our nuclear medicine guy-- it's funny, when I saw the software, I was just wise enough to think to myself, this could be interesting, but had no idea how we would implement it. I, again, voluntold my partner who is really-- Doug Murray is just an incredible guy. He worked with the MIM folks. They had no algorithm, they had no process for how to incorporate what we wanted to do with their software.

Doug's been working with them now for about two years. We actually have a research project going on with them. Doug was really, again, the brains behind figuring out how we could really utilize MIM. When we started out, the IR physicians were doing all the contouring, and we just were doing a not great job with it and we run a--

[Dr. Aparna Baheti]
Oh my God, the drawing of the circles, I would be so happy if I never had to draw another circle around a liver tumor ever in my life again.

[Dr. Jayson Brower]
It's miserable. We actually trained our 3D techs and our 3D lab to do it and we have one who's in charge of it and she's fantastic. She can do a whole MIM processing in about 15 minutes and it's spot on every time.