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Is Proton Therapy For Prostate Cancer Covered By Medicare

Proton Therapy Treatment For Prostate Cancer Patients

Which is Better – Surgery vs. Radiation for Prostate Cancer?

Proton therapy is a form of radiation treatment for cancer patients. Also called proton beam therapy, proton therapy involves focusing proton particles into a beam, which is then delivered to the cancer cells in a non-surgical procedure. The positively charged particles can be controlled to stop at the tumor site, enabling the cancerous tissues to be destroyed with high levels of radiation without causing damage to nearby healthy tissue and vital organs. Proton therapy is considered more precise than other types of radiation therapy. It is also non-surgical, non-invasive, and has minimal side effects. Proton therapy treatment requires little to no recovery time, and the radiation has very little impact on a patients energy level compared to other cancer treatment options.

Proton therapy exhibits higher success rates in prostate cancer patients.

According to a study published by the University of Florida, prostate cancer patients who received proton therapy treatment were found to be free of cancer progression for five years after their treatment. Patients with low to medium risk prostate cancer experienced a success rate of 99%, while those with high risk prostate cancer experienced a success rate of 76%.

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Does Medicare Pay For Cancer Radiation Treatments

Original Medicare Medicare Part A and Part B covers radiation treatments for cancer that are performed in either a hospital or a freestanding clinic. Medicare Advantage plans are required by law to cover everything that Original Medicare covers, but Medicare Advantage plans may provide additional benefits.

You may still be responsible for out-of-pocket costs associated with your radiation treatment. A Medigap policy may help cover your out-of-pocket costs. Talk with your plans provider to find out exactly what benefits are available to you.

Types of Radiation Therapy Medicare Covers

Internal Radiation
Medicare covers this type of treatment in which radiation is delivered in a liquid or solid form, typically through an IV, pills or small pellets that are inserted inside your body.
External Beam Radiation
Medicare covers this type of treatment in which a machine directs beams of energy to a specific site on or inside your body in order to target a tumor while limiting exposure to the area around it.
Proton Beam Therapy
Medicare generally covers proton beam therapy. This is a more targeted treatment than external beam radiation because the proton beam stops after reaching the cancer. Proton beam therapy is a relatively new form of radiation treatment, and there may be certain requirements for coverage. Before committing to the treatment, make sure you check with Medicare or your Medicare Advantage plan provider to see that its covered in your case.

Proton Therapy For Recurrent Prostate Cancer

For those with a recurrence of prostate cancer, additional radiation therapy with photons can increase the risk of side effects and isnt generally recommendation. In these cases, proton therapy can provide an optimal dose of radiation to your tumor while protecting the healthy tissue surrounding the prostate. This puts radiation back on the table as a treatment option for recurrent prostate cancer.

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What To Expect With Radiation Treatments

If you and your doctor have decided that radiation therapy is right for your type of cancer, youll begin with a radiation simulation. During the simulation, youll lie on a table and a CT scan or X-ray will be done to see where your cancer is and where the energy beams should focus.

After the images are taken, your treatment team will mark the area where radiation is needed. This will help the team direct the radiation precisely to the right place.

During radiation therapy, youll likely have treatments 5 days per week for up to 10 weeks. How much radiation you receive and for how long will depend on the extent and type of your cancer.

Depending on the kind of treatment you get, you may experience

Is It Covered By Insurance

Proton Beam Therapy for Prostate Cancer

Emory Proton Therapy Center is contracted with many private insurance plans as well as Medicare. If coverage is denied, a physician from the insurance company will usually contact your physician at the proton center to discuss the insurance companys policy on proton therapy. Depending on the company, the peer-to-peer review may also provide your physician with an opportunity to explain why proton therapy is recommended in your care. If treatment is still denied, our insurance team will work closely with you to file appeals.

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Which Treatments Are Best In Keeping Men In Remission

Here is your opportunity to compare prostate cancer treatments. Over 129,000 patients underwent PSA monitoring after treatment to see which treatments were most effective at keeping the cancer in remission. The charts show which treatments are more likely to leave patients Prostate Cancer Free, for how many years. Share this data, talk with your Doctor, or multiple Doctors and make an informed decision. Select the treatment option, that is best for you.

Compare Prostate Cancer Treatments by gathering information about your own Prostate Cancer Diagnosis. Your Doctor will provide three elements that describe your prostate cancer. Your PSA, Stage and Gleason Score. These three elements help you determine your risk group. Find and select your Risk Group in the table below. This will take you to the comparing prostate cancer treatments page, where you can select different prostate cancer treatments on an interactive chart and graphically see their effectiveness over time.

The treatments included in this study are Prostate Surgery or Prostatectomy, , Brachytherapy or Seeds, High Dose Rate Radiation, HDR, External Beam Radiation Therapy or EBRT, Androgen Deprivation Therapy, ADT, or Hormone Treatment, Proton Therapy, High-Intensity Focused Ultrasound, HIFU, Cryotherapy, Cryo and Hypo-Fractionated External Beam Radiation Therapy. For more advanced prostate cancer, treatments are combined to increase effectiveness.

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Side Effects Of Radiation Therapy

Compared to earlier radiation methods, these modern techniques reduce the chance of urinary and bowel problems.

With several treatment options available, your doctor will work with you to develop and oversee a treatment plan that precisely addresses your prostate cancer while minimizing the risk to surrounding tissues.

This is why it is important to choose an experienced radiation oncologist who specializes in the management of prostate cancer. High volume centers where practitioners have significant experience and treat large numbers of patients with prostate cancer may be associated with good outcomes and fewer lasting problems related to treatment. The majority of patients who undergo radiation do not have permanent effects on bowel or urinary function, and patients who develop erectile difficulty after these therapies can often be treated successfully with medications such as sildenafil or tadalafil.

Radical Prostatectomy vs. Radiation: How to Compare the Results

Making a decision about prostate cancer treatment is not easy. When considering radiation therapy or radical prostatectomy, one of your top concerns is seeking reassurance that your cancer will be cured following treatment.

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Copayments Coinsurance And Deductibles

Depending on the coverage you have, you’ll likely be required to pay a portion of your treatment costs in copayments, coinsurance and deductibles.

  • Copayment: A predetermined and fixed dollar amount that beneficiaries may pay for specific treatments
  • Coinsurance: The percentage of treatment costs that a beneficiary must pay out-of-pocket
  • Deductible: An annual amount that beneficiaries are required to pay on their own before coverage begins

The best way to determine exactly what your plan will cover is by speaking with your plan administrator or your health care provider.

Questions To Ask Your Doctor

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To estimate how much your care will cost, ask your medical team:

  • How much do the recommended treatments and medications cost?
  • How much of the treatment does my insurance cover?
  • What do the costs of appointments look like with insurance, without insurance, with Medicaid, or with Medicare?
  • If you recommend a procedure, how much does that cost? Will it involve staying in a hospital, and if so, whatâs the typical cost for that?
  • What are some resources for help with paying medical bills?

Also, check with your insurance plan so that you know what your plan covers and which providers and facilities are âin networkâ for you.

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We Fight For The Care You Need

If you have been diagnosed with cancer, it is critical that you receive the care you need based on your doctors recommendations. It should be you and your doctors that decide your treatment plan, not your insurance company. If your doctors have prescribed proton therapy, but your insurance company will not pay for it, we can help. Whether your claim for proton therapy has just been denied or you are preparing to appeal the insurance denial, our attorneys have the experience to fight for your health benefits and the treatment you need.

Is Proton Beam Therapy Safer Than Other Options

Due to the concentrated nature of the radiation in proton therapy, there are usually fewer side effects than in conventional radiation therapy. Thats because theres less damage to healthy tissue around the tumor.

People who have proton therapy may have a significantly lower risk of short- and long-term complications compared with people receiving traditional photon therapy, according to a research study . These findings show a two-thirds reduction of adverse events in the 90 days after treatment, as well as a significantly reduced risk of having difficulties moving and performing daily activities.

However, long-term data is lacking on the safety of proton beam therapy. Furthermore, due to the high cost of treatment, current research has been limited in terms of demographics.

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How Do I Know If Im A Good Candidate For Proton Therapy At Johns Hopkins

Proton therapy is used to target cancers located near vital organs such as the brain, spinal cord, heart, lung, liver and reproductive organs. Many factors are considered when choosing a cancer treatment approach. The cancer specialists at the Johns Hopkins National Proton Center will help you determine the best course of treatment for your unique condition.

Does Insurance Cover Proton Therapy

Proton Therapy Prostate Cancer Survival Rates

Proton therapy was first discovered in the early 1900s, and approved by the U.S. Food and Drug Administration for cancer treatment in 1988. Nevertheless, proton therapy tends to be more expensive than traditional radiation and is still not covered by many insurance companies. There are various reasons insurance companies will deny coverage for proton therapy, including claiming it is experimental or not medically necessary for your particular cancer diagnosis. Proton therapy may still provide the life-saving treatment you need. That is why it is crucial you consult with legal counsel with experience in dealing with health benefits denials such as the attorneys at DeBofsky Law. We can advise you on the specific terms and limitations in your health plan, and how to fight for coverage of the cancer treatment you need.

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Obesity And Dietary Habits

High-fat intake, the Western diet, obesity, and sedentary behavior are all associated with a higher incidence of prostate cancer. High calcium intake and a diet high in milk products can increase the risk. After being diagnosed with prostate cancer, calcium can increase the risk of aggressive types. On the other hand, whole milk increases the risk of recurrence of prostate cancer. Obese and overweight men are particularly prone to this increase in recurrence. Another dietary risk factor is vitamin D insufficiency. Meat consumption increases cancer risk, while fish consumption lowers the mortality rate.

For Prostate Cancer Medicare Covers The Following Screenings Once Every 12 Months For Men Over 50

A PSA test doesnt cost you anything if you get it done by a doctor that accepts Medicare assignment, but you may pay a fee if the doctor does not. For a DRE, you will pay 20 percent of the Medicare-approved amount for the exam and your physicians services. Youll also be responsible for the Part B deductible. Finally, a copayment will be due if the exam is done in a hospital outpatient setting.

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Proton Therapy Vs Other Treatments

Which treatment you should have is not as simple as comparing proton therapy to chemotherapy, surgery, or hormone treatments. Each serves a specific purpose.

Your treatment will depend, in large part, on how aggressive the cancer is and its stage at diagnosis. Other things to consider are:

  • previous treatments
  • other health conditions that might interfere with certain treatments

Proton therapy is more expensive and not widely available. Your doctor will look at the total picture when recommending treatment.

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The 4 Types of Prostate Cancer Treatment | Prostate Cancer Staging Guide

An enlarged prostate can also be the cause of other problems. If the enlarged prostate is causing symptoms, the best treatment would be a natural remedy. In the meantime, there are treatments for a wide range of conditions that cause a man to experience pain. A common surgical procedure involves an electric loop, laser, or electro-stimulation. The procedure is a safe and effective option for treating enlarged or symptomatic BPH.

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How Is Prostate Cancer Treated

There are several options your doctor might consider to treat prostate cancer. Their methods typically depend on how advanced your cancer is, as well as the Surveillance, Epidemiology and End Results stage, which determines whether your cancer is localized to one area or has begun to spread throughout the body.

Typical treatments for prostate cancer include:

  • Active surveillance

Payment & Insurance Coverage Options For Proton Therapy

Full coverage: While proton beam cancer therapy treatment is covered by Medicare, private insurance coverage varies. Some companies do not reimburse for the service or only cover treatment for certain diagnoses. If your insurance carrier does pay for proton therapy, patients often incur little or no net out-of-pocket expenses after deductibles and annual maximum payments are met.

Case-by-case coverage: In this situation, our team of cancer specialists and physicians will work directly with your insurance plan to seek authorization for care by providing appropriate documentation to support the medical necessity of treatment.

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Why Should I Go To Johns Hopkins For Proton Therapy

  • The Johns Hopkins National Proton Center at Sibley Memorial Hospital is one of the most comprehensive centers in the world and provides precise, personalized cancer care delivered by some of the worlds leading experts.
  • Our center is one of only a few with a dedicated pediatric team, which collaborates with Childrens National Hospital one of the top 10 in the nation for pediatric cancer care.
  • Our center is equipped with state-of-the-art technology, including pencil beam scanning, image guidance equipment, dedicated CT/MRI treatment simulators, a dedicated research gantry and translational laboratory space.
  • The Sidney Kimmel Comprehensive Cancer Center at Johns Hopkins is a world leader in cancer research. This research is critical to determining which type of treatment is best for each individual, helping us make cancer treatment more personal, precise and effective.

Original Medicare Covers Chemotherapy And Cancer Treatments

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Medicare Part A and Part B make up Original Medicare, which covers some hospital and medical care needs.

Medicare Part B covers doctor visits, surgeries and outpatient hospital services, including chemotherapy. Medicare Part A provides coverage for inpatient hospital care.

How Medicare pays for chemotherapy depends on where you receive your treatment:

  • Hospital outpatientYou will typically pay a Medicare Part B copayment for chemotherapy received in a hospital outpatient setting. Your copay will typically be a set dollar amount, rather than a percentage of costs.
  • Doctors office or freestanding clinicAfter meeting your Part B deductible , youre typically responsible for paying 20% of the Medicare-approved amount for the treatment.

Original Medicare can also provide coverage for the following cancer treatment and screening services:

  • Prostate cancer screenings

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Intermittent Or Continuous Therapy

Once prescribed, hormone therapy used to continue for life, but scientists are now reevaluating that strategy and investigating whether hormone therapy can be taken intermittently, with so-called holidays from treatment. The thinking is that this may not only help restore quality of life as, for example, returning libido and sexual health but also delay the hormone resistance that eventually develops in men taking hormone therapy.

Clinical trials evaluating whether intermittent therapy is as effective or more effective than continuous therapy are now under way, so it is too early to say for sure.

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What Cancer Screenings Does Medicare Cover

Medicare covers a variety of preventative screenings related to different kinds of cancer including breast cancer, cervical cancer, prostate cancer, lung cancer and colorectal cancer.

How each screening is covered and how often you can get them vary. Coverage may also be dependent on you meeting specific conditions. The following are a list of some of the preventative screenings for cancer that Medicare will cover.

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Secondary Treatment Following Relapse

Hormone therapy may also be used as a secondary or salvage treatment when PSA levels rise following initial prostate cancer treatment, indicating the cancer has returned. This situation is known as biochemical recurrence. The salient points to keep in mind are that hormone therapy is most often used as a salvage treatment when PSA doubling time is less than six months, indicating that the cancer is aggressive or may have already metastasized.


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