Treating a Patient Denied Coverage Based on Not Conforming to NCCN Guidelines

Posted by James L. Mohler, MD | Feb 2020

James L. Mohler, MD, presented “Treating a Patient Denied Coverage Based on Not Conforming to NCCN Guidelines” for the Grand Rounds in Urology audience in February, 2020.

How to cite: Mohler, James L. “Treating a Patient Denied Coverage Based on Not Conforming to NCCN Guidelines” February, 2020. Accessed Apr 2024. https://grandroundsinurology.com/treating-a-patient-denied-coverage-based-on-not-conforming-to-nccn-guidelines/

Treating a Patient Denied Coverage Based on Not Conforming to NCCN Guidelines – Summary:

James L. Mohler, MD, Chair of the National Comprehensive Cancer Network (NCCN) Prostate Panel, discusses approaches for urologists dealing with insurance coverage denial for patients who do not fit within NCCN guidelines for prostate cancer. He outlines the iterative, bias-free process of creating the guidelines, which allows for a quick response to the latest research. Dr. Mohler further details how the guidelines value efficacy, quantity/quality of evidence, consistency of evidence, and safety above affordability, and how this can lead to denial of coverage. He then outlines talking points for overcoming guideline-based reasons for rejection from insurance providers.

About The Author

James L. Mohler, MD

James L. Mohler, MD, is the Associate Director and Senior Vice President for Translational Research, the Chief of Inter-Institutional Academics, and a Professor of Oncology at Roswell Park Comprehensive Cancer Center in Buffalo, New York. He also serves as Professor of Urology at the University of Buffalo School of Medicine and Biomedical Sciences and Adjunct Professor of Urology and Member of UNC-Lineberger Comprehensive Cancer Center at the University of North Carolina. Dr. Mohler has been engaged in translational research for over 30 years. His activities have largely focused on the role of the androgen receptor (AR) in prostate cancer (CaP) recurrence after androgen deprivation therapy (ADT), as well as racial differences in CaP aggressiveness. These research activities include the Program Project-funded “Prostate Cancer: Transition to Androgen-Independence” and the DOD Prostate Cancer Research Program-funded “North Carolina-Louisiana Prostate Cancer Project (PCaP),” the largest population-based CaP study ever conducted (2258 men with newly diagnosed CaP at 11 institutions). PCaP sought to compartmentalize the reasons for increased CaP mortality in African Americans. Thus far, racial differences in interactions between African American CaP patients and the American Healthcare System seem to outweigh the impact of racial differences in CaP biology and both the host’s environment (diet) and genetics. PCaP’s P01 demonstrated that tissue levels of dihydrotestosterone (DHT) in CaP that recurs during ADT are sufficient for AR activation, which leads to the re-purposing of abiraterone to treat castration-recurrent CaP. Dr. Mohler’s focus on AR and ADT continues with 2 grants to support the characterization of the 3 pathways for intracrine metabolism of testosterone and DHT, as well as a novel therapeutic against DHT production. His focus on racial disparities in CaP continues with a new grant to study financial distress.

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