To: The United States House of Representatives and The United States Senate
Repeal Section 634 of the Taxpayer Relief Act
Dear Congress:
I am writing to you today out of concern about a provision that was included in the American Taxpayer Relief Act of 2012. Section 634 of that Act decreases Medicare outpatient reimbursement for Cobalt 60 stereotactic radiosurgery (“Gamma Knife®”) for brain disorders by more than 50%. This drastic and unsustainable cut will reduce access to an important treatment for Medicare beneficiaries, result in certain patients being treated with less clinically effective and more risky technologies, and potentially impose cost increases on the Medicare program over time.
Stereotactic radiosurgery (SRS) refers to a range of minimally invasive modalities used to target high-energy radiation to small areas in the body. Gamma Knife is a type of SRS designed specifically to treat brain tumors and other complex brain disorders by delivering precision results not available with other types of SRS equipment. The precision afforded by Gamma Knife is critical to outcomes achieved in patients, especially when the disease is in close proximity to sensitive brain structures that would otherwise be exposed to two or three times the radiation when treated with other technologies. Unfortunately, the reimbursement cut imposed by Section 634 will make it very difficult, if not impossible, to use Gamma Knife for Medicare beneficiaries in the future.
Further, Section 634 misaligns reimbursement levels for Gamma Knife with other SRS technologies, which over time could result in cost increases to the Medicare program. Purported to bring Gamma Knife in line with other SRS technologies, Section 634 seems to assume that Gamma Knife can be compared on a single session to single session basis with other SRS technologies. But the truth is that more than 50% of the time, other SRS technologies require between 3 and 5 fractions to achieve the same results as one Gamma Knife fraction in brain treatments. And even where other SRS technologies can accomplish the same results as Gamma Knife with one fraction, the reimbursement methodologies are not identical. When all related reimbursement codes are included, Gamma Knife and other SRS technologies have similar reimbursements on a fraction by fraction basis. Thus, the Section 634 reimbursement cut does not bring Gamma Knife in line with other SRS technologies, but instead misaligns the reimbursements significantly. This point appears to be supported by the Centers for Medicare and Medicaid Services (CMS) who just one month before enactment of Section 634 declined to modify the Gamma Knife reimbursement based on their own substantial cost data.
I can only assume that the significant time pressures associated with enactment of the American Taxpayer Relief Act did not allow for a sufficient analysis of the potential adverse impacts of this provision on Medicare beneficiaries, or the added costs this reimbursement modification may bring to the program. Medicare beneficiaries deserve a more complete and thorough review before having their benefit hollowed out for this critically important treatment for serious brain disorders. Section 634 should be repealed before its April 1 effective date so that CMS can properly review the current reimbursement policy and determine whether it should be modified.
Thank you for taking the time to read this letter, and please feel free to contact me at with any questions.
I am writing to you today out of concern about a provision that was included in the American Taxpayer Relief Act of 2012. Section 634 of that Act decreases Medicare outpatient reimbursement for Cobalt 60 stereotactic radiosurgery (“Gamma Knife®”) for brain disorders by more than 50%. This drastic and unsustainable cut will reduce access to an important treatment for Medicare beneficiaries, result in certain patients being treated with less clinically effective and more risky technologies, and potentially impose cost increases on the Medicare program over time.
Stereotactic radiosurgery (SRS) refers to a range of minimally invasive modalities used to target high-energy radiation to small areas in the body. Gamma Knife is a type of SRS designed specifically to treat brain tumors and other complex brain disorders by delivering precision results not available with other types of SRS equipment. The precision afforded by Gamma Knife is critical to outcomes achieved in patients, especially when the disease is in close proximity to sensitive brain structures that would otherwise be exposed to two or three times the radiation when treated with other technologies. Unfortunately, the reimbursement cut imposed by Section 634 will make it very difficult, if not impossible, to use Gamma Knife for Medicare beneficiaries in the future.
Further, Section 634 misaligns reimbursement levels for Gamma Knife with other SRS technologies, which over time could result in cost increases to the Medicare program. Purported to bring Gamma Knife in line with other SRS technologies, Section 634 seems to assume that Gamma Knife can be compared on a single session to single session basis with other SRS technologies. But the truth is that more than 50% of the time, other SRS technologies require between 3 and 5 fractions to achieve the same results as one Gamma Knife fraction in brain treatments. And even where other SRS technologies can accomplish the same results as Gamma Knife with one fraction, the reimbursement methodologies are not identical. When all related reimbursement codes are included, Gamma Knife and other SRS technologies have similar reimbursements on a fraction by fraction basis. Thus, the Section 634 reimbursement cut does not bring Gamma Knife in line with other SRS technologies, but instead misaligns the reimbursements significantly. This point appears to be supported by the Centers for Medicare and Medicaid Services (CMS) who just one month before enactment of Section 634 declined to modify the Gamma Knife reimbursement based on their own substantial cost data.
I can only assume that the significant time pressures associated with enactment of the American Taxpayer Relief Act did not allow for a sufficient analysis of the potential adverse impacts of this provision on Medicare beneficiaries, or the added costs this reimbursement modification may bring to the program. Medicare beneficiaries deserve a more complete and thorough review before having their benefit hollowed out for this critically important treatment for serious brain disorders. Section 634 should be repealed before its April 1 effective date so that CMS can properly review the current reimbursement policy and determine whether it should be modified.
Thank you for taking the time to read this letter, and please feel free to contact me at with any questions.
Why is this important?
Section 634 of the Taxpayer Relief Act decreases Medicare outpatient reimbursement for Cobalt 60 stereotactic radiosurgery (“Gamma Knife®”) for brain disorders by more than 50%. Which is below the cost of providing a procedure. This will reduce access to an important treatment for Medicare beneficiaries, result in certain patients losing access to a viable procedure and potentially impose cost increases on the Medicare program over time.