SCINTIX Therapy Leverages Breakthrough Device Status to Garner Accretive New Technology Reimbursement

In a landscape of declining Medicare reimbursements for conventional radiotherapy over the past decade, SCINTIX^® therapy stands alone as a new modality in radiation therapy that bucks the trend.

In January 2024, SCINTIX therapy was granted accretive reimbursement compared to other radiotherapy modalities. The Centers for Medicare and Medicaid Services (CMS) established a national payment rate for SCINTIX therapy under the New Technology Ambulatory Payment Classification (NT-APC) pathway granting two new reimbursement codes; one for the SCINTIX modeling pre-treatment procedure (C9794) and one for the actual SCINTIX delivery (C9795). To qualify for this status, the new technology must be a comprehensive service or procedure that is truly new and significant enough to warrant having a unique code. The creation of these codes acknowledges SCINTIX therapy as a revolutionary approach to treating cancer patients and represents the most positive change in radiotherapy reimbursement in nearly 20 years. “We are grateful that CMS recognizes the potential of SCINTIX therapy for patients with all stages of indicated cancers and has addressed payment as a barrier to clinical adoption,” said Susan Thompson, Senior Director of Patient Access at RefleXion.

Accretive payment for SCINTIX therapy is even more exciting given that the radiation oncology sector is experiencing substantial cuts compared to other medical specialties. The establishment of new codes and accretive reimbursement is critical to ensure patient access to the most innovative and groundbreaking technology. Without accretive reimbursement, there is little incentive for healthcare providers to scale the learning curve to adopt new technology, or for the industry to invest in research and development of novel therapeutic approaches which ultimately improve patient care. SCINTIX therapy is reimbursed at nearly twice the rate of stereotactic body radiosurgery, a form of image-guided radiotherapy, which reflects the added work of delivering a groundbreaking new technology.

SCINTIX therapy uses live signals from the cancer itself to direct the radiation beam for treatment. To begin, the patient is injected with the radiopharmaceutical fludeoxyglucose (FDG) and then rests while the cancer cells uptake the FDG. Following the uptake, a PET scan is performed to ensure the signal emitted from the tumors is sufficient for treatment. Once confirmed, the clinician will proceed with the planning process and ultimately treatment. SCINTIX therapy is a non-invasive procedure delivered in three to five sessions. To learn more about how this groundbreaking technology works, click here.

“We are grateful that CMS recognizes the potential of SCINTIX therapy for patients with all stages of indicated cancers and has addressed payment as a barrier to clinical adoption,”

Susan Thompson
Senior Director of Patient Access

Securing accretive reimbursement for SCINTIX therapy in the hospital outpatient setting was a major accomplishment; however, roughly 40% of cancer patients receive treatment in freestanding centers ^[1], which cannot bill using the C-codes described above. To provide these patients access to this groundbreaking technology so that they could be treated closer to where they live, new codes were needed to ensure reimbursement in both sites of service.

Less than a year later in November 2024, CMS announced that it would expand the reimbursement for SCINTIX therapy by replacing the existing C-codes (C9794 and C9795) with G-codes (G0562 and G0563) to allow for payment in both hospitals and freestanding centers. These new SCINTIX G-codes will become effective on January 1, 2025.

In addition to granting G-codes, CMS also created a professional component for the SCINTIX modeling session, which enables physician payment for this complex procedure.

Despite the challenging reimbursement landscape, the reimbursement for SCINTIX therapy is promising. The creation of reimbursement codes for SCINTIX therapy by CMS supports the adoption of this groundbreaking therapy and most importantly, enables access to SCINTIX therapy for more patients – even those with metastatic disease. To hear more about how SCINTIX therapy is changing lives, check out this interview with Susanne Kluh, a patient recently treated with SCINTIX therapy at City of Hope Comprehensive Cancer Center in Southern California.

[1] MACRA and Alternative Payment Models: Developing Options for Value-based Care. 115th Cong. 4 (2017) (testimony of Brian Kavanagh) https://docs.house.gov/meetings/IF/IF14/20171108/106599/HHRG-115-IF14-Wstate-KavanaghB-20171108.pdf