We have had this issue over the last several years. Medicare changed their policy to allow only 4 PETCT scans for a lifetime for a diagnosis. Many of the private payers have followed and only are allowing PETCT scans at initial diagnosis and/or if something it seen with what they determine as conventional imaging. We have found this most difficult in our patients who have subcutaneous or intransit disease for standard imaging doesn’t give us a good representation of their disease status.

Our institution has transitioned to utilizing a radiology authorization team. This is a team of non clinicians interpreting and providing clinical information can sometimes trigger a delay in a review or result in a peer to peer. Overall the team is pretty good and this service has been helpful to alleviate some work load from our secretaries. The only pitfall is when they have multiple auths to that require peer to peer and we as the clinicians are only provided with a short window of time to obtain this.

Most of the pvt payor companies we deal with have transitioned to a scheduled peer to peer appointment call. The negatives are that at times when an urgent auth is needed and no MD is available this can delay care rendered to the pt.
Positives: you can (most of the time) choose the time when you would like to conduct the call, you can plan and prepare for it rather than having a reactive call with a scheduler/ secty calling asking you to get on the phone with the doctor who is on the line at that moment. I find the docotor is prepared for the call and that has contributed to a quicker and more often pleasant call.
At times when I really need an auth before the next day, I have been successful with speaking to an MD within a short time frame or scheduled for later in the day/ just after clinic hours.

Indeed though this is just one example of the numerous areas of a patients care that requires review and authorization.

In the time from my last reply to now….I too learned there will be no more “on the fly” peer-to-peers. It is a scheduled call.

One more thing…I have learned from speaking to many physician reviewers, the majority of the time, they are not oncologists! Often they are internists, or other specialty MDs, that just sit with guidelines in front of them- and that is how decisions are made. I understand the rationale by ensuring tests are indeed medically necessary and to be economically prudent, but as we all know….melanoma does not like to play by the rules, and often certain situations require certain specialty radiologic imaging. Decisions made by non-oncology physician providers are not always in the best interest of the patients (at least this is my experience…at times, now always).