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A 63-year-old African-American male presents to the emergency department with sudden onset of painless gross hematuria for one day. He reports dark red urine with clots causing occasional dysuria, difficulty emptying, and light-headedness.

Challenging case: Hematuria in man with a history of prostate Ca

Dr. De La Cerda provides an overview of a patient case involving a 68 year-old male presenting with severe back pain, with an analysis of the clinical presentation, workup, and medical history.

Bone Predominant mCRPC Patient Case

Video content above is prompted by the following:

What are your initial impressions of the case?

Video Series

The FDA has accepted a Biologics License Application (BLA) seeking approval of nivolumab (Opdivo) co-formulated with Halozyme’s proprietary recombinant human hyaluronidase (rHuPH20), or subcutaneous nivolumab, for the treatment of patients with all previously approved solid tumor indications for nivolumab as a monotherapy, monotherapy maintenance following completion of combination therapy with nivolumab plus ipilimumab (Yervoy), or in combination with chemotherapy or cabozantinib (Cabometyx).

Nivolumab is currently approved under several indications, including in combination with ipilimumab for the first-line treatment of patients with intermediate- or poor-risk advanced renal cell carcinoma (RCC), in combination with cabozantinib for the first-line treatment of patients with advanced RCC, for the treatment of patients with advanced RCC who have received prior anti-angiogenic therapy, and in combination with cisplatin and gemcitabine for the first-line treatment of patients with unresectable or metastatic urothelial carcinoma.

The FDA is set to have a decision regarding the subcutaneous nivolumab formulation on or by December 29, 2024.

 According to a news release from Bristol Myers Squibb,

 approval of the formulation would make it the first and only subcutaneously administered PD-1 inhibitor.

“We believe subcutaneous nivolumab has the potential to make a significant difference in the lives of patients, which is reinforced by the FDA’s acceptance of our application,” said Gina Fusaro, PhD, vice president, global program lead, Bristol Myers Squibb, in the news release.

 “Opdivo is a foundational PD-1 inhibitor approved for many different types of cancer, and our continued investment in research that puts patients first remains a priority. If approved by the FDA, the subcutaneous administration of nivolumab would provide patients and their physicians with a new option that delivers the same well-known benefits as IV Opdivo but with the improved convenience of an injection administered in 3 to 5 minutes rather than a 30-to-60-minute infusion.”

The BLA submission is supported by findings from the phase 3 CheckMate-67T trial (NCT04810078), in which subcutaneous nivolumab met the study’s co-primary end points by demonstrating noninferiority to intravenous (IV) nivolumab regarding time average nivolumab serum concentration over 28 days (C

; geometric mean ratio [GMR}, 2.098; 90% CI, 2.001-2.200) and minimum serum concentration at a steady state (C

Data from the study, which were presented at the 2024 American Society of Clinical Oncology Genitourinary Cancers Symposium in San Francisco, California,

 also showed that subcutaneous nivolumab demonstrated noninferiority to IV nivolumab in the key powered secondary end point of objective response rate (ORR). Specifically, the subcutaneous arm demonstrated an ORR of 24.2% (95% CI, 19.0-30.0) per blinded independent central review (BICR), compared with 18.2% (95% CI, 13.6-23.6) in the IV arm.

The safety profile for subcutaneous nivolumab was consistent with that of the IV formulation. Among patients who received the subcutaneous formulation, 8.1% experienced injection-site reactions, with all being low-grade and transient. Deaths due to study drug toxicity occurred in 3 patients in the subcutaneous arm and 1 patient in the IV arm. Most deaths that occurred during the study were due to disease progression.

In total, the phase 3, open-label CheckMate-67T trial enrolled 495 patients with advanced or metastatic ccRCC who had received prior systemic therapy. Patients were randomly assigned 1:1 to receive 1200 mg subcutaneous nivolumab plus rHuPH20 every 4 weeks (n = 248) or to 3 mg/kg IV nivolumab every 2 weeks (n = 247) for up to 2 years of treatment or until disease progression, unacceptable toxicity, withdrawal, or death.

The co-primary pharmacokinetic end points for noninferiority testing were C

 of subcutaneous nivolumab vs IV nivolumab. The key secondary end point was ORR per BICR.

Final completion of the CheckMate-67T study is expected in January 2026.

1. U.S. Food and Drug Administration accepts Bristol Myers Squibb’s application for subcutaneous nivolumab (nivolumab and hyaluronidase). News release. Bristol Myers Squibb. May 6, 2024. Accessed May 7, 2024. https://news.bms.com/news/corporate-financial/2024/U.S.-Food-and-Drug-Administration-Accepts-Bristol-Myers-Squibbs-Application-for-Subcutaneous-Nivolumab-nivolumab-and-hyaluronidase/default.aspx

2. Bristol Myers Squibb announces updated action date by the U.S. Food and Drug Administration for subcutaneous nivolumab (nivolumab and hyaluronidase). News release. Published online and accessed May 21, 2024. https://investors.bms.com/iframes/press-releases/press-release-details/2024/Bristol-Myers-Squibb-Announces-Updated-Action-Date-by-the-U.S.-Food-and-Drug-Administration-for-Subcutaneous-Nivolumab-nivolumab-and-hyaluronidase/default.aspx

3. George S, Bourlon TB, Chacon MR, et al. Subcutaneous nivolumab (NIVO SC) vs intravenous nivolumab (NIVO IV) in patients with previously treated advanced or metastatic clear cell renal cell carcinoma (ccRCC): Pharmacokinetics (PK), efficacy, and safety results from CheckMate 67T. 

4. A study of subcutaneous nivolumab versus intravenous nivolumab in participants with previously treated clear cell renal cell carcinoma that is advanced or has spread (CheckMate-67T). ClinicalTrials.gov. Last updated March 1, 2024. Accessed May 7, 2024. https://clinicaltrials.gov/study/NCT04810078

The FDA is set to have a decision regarding the subcutaneous nivolumab formulation on or by December 29, 2024. 

News

FDA accepts BLA for subcutaneous nivolumab in solid tumors

I have a question about G2211. As a pediatric urologist, am I allowed to report this code for patients who meet the criteria regardless of payer? Our practice has encouraged it to be used for adult urology patients who have Medicare but not in pediatric urology patients because they are not of Medicare age, and they believe this is a Medicare-specific code.

We had addressed the definition and use of the Healthcare Common Procedure Coding System (HCPCS) code G2211 in previous 

 articles, including that of May 1, 2024.

 As a quick reminder, the HCPCS G2211 add-on code descriptor is the following:

“Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)”

HCPCS codes can be used and accepted by any insurer. The insurer’s payment policies will determine whether it gets reimbursed. From our standpoint, it is reasonable to add this HCPCS code to any patient who meets the appropriate criteria, notwithstanding their insurance coverage. If a practice has determined in writing that there are insurers whose policies advised that they will not accept this code, it seems reasonable not to report that code to that insurer even when criteria are met.

1. Rubenstein J, Painter M. Medicare’s G2211 and thoughts on how to best use it in urology. 

May 1, 2024. Accessed December 16, 2024. https://www.urologytimes.com/view/medicare-s-g2211-and-thoughts-on-how-to-best-use-it-in-urology

Send coding and reimbursement questions to Jonathan Rubenstein, MD, and Mark Painter c/o

The information in this column is designed to be authoritative, and every effort has been made to ensure its accuracy at the time it was written. However, readers are encouraged to check with their individual carrier or private payers for updates and to confirm that this information conforms to their specific rules.

"If a practice has determined in writing that there are insurers whose policies advised that they will not accept this code, it seems reasonable not to report that code to that insurer even when criteria are met," write Jonathan Rubenstein, MD, and Mark Painter.

Urology Coding Q&A: Can G2211 be reported regardless of payer?

Regarding your article on the Medicare proposed fee schedule rules for 2025,

 can you further explain how the practice expense (PE) relative value unit (RVU) is changing for the cystoscopy? I’m not familiar with the cystoscopy packs that are mentioned in the article or how they affect an in-office cystoscopy.

In the article you are referring to, we stated that several urology codes will see their PE valuation change due to updates in supply valuation. A practitioner is reimbursed by the total RVU of a procedure, which consists of the sum of the work RVU, the PE RVU, and the malpractice RVU. In the case of cystoscopy procedures, the work RVU is unchanged. However, the Centers for Medicare & Medicaid Services (CMS) felt that the reimbursement for some of the supplies and equipment involved in some cystoscopy procedures was incorrectly valued. Many cystoscopy procedures have PE valuation that includes either drapes for cystoscopy (supply code SA045) or a full cystoscopy kit (supply 

code SA058), which includes several items such as drapes and other equipment necessary for the procedure to be performed. Medicare felt that the cost and, therefore, reimbursement of these packs was greater than the sum of its components. Therefore, with the help of the Relative Value Update Committee (RUC), these packs were revalued, with the SA045 dropping from $17.33 to $14.99 and SA058 dropping from $113.70 to $37.63. These updates will result in a reduction in the PE RVU portion of the total RVU; therefore, the reimbursement for the procedure will similarly be reduced. Please note that in the Medicare final rule, it was determined that SA058 changes would be phased in over 4 years to allow practices to adjust to the changes. As a result of the changes and the programmed phase-in of the changes, the cystoscopy code total RVU for the office setting will be 8% lower in 2025 than the current value. It is important to note that the kit packs and their corresponding numbers are not reported to Medicare separately and instead are used by CMS and the RUC in the process of developing the RVUs for these procedures.

"As a result of the changes and the programmed phase-in of the changes, the cystoscopy code total RVU for the office setting will be 8% lower in 2025 than the current value," write Jonathan Rubenstein, MD, and Mark Painter.

What’s changing with reimbursement for cystoscopy packs

The marriage process requires careful thought about several financial situations many couples will likely face. With financial disagreements being a leading cause of marital problems, why not tackle them ahead of time? This may include reaching out to your financial planner and other legal and tax advisers well in advance of the nuptials.

The starting point is to have a candid discussion with your fiance/fiancee about your overall finances

For example, how much debt is each of you bringing to the marriage? What about savings? How is each of your credit ratings? What are your income and tax circumstances going to look like? The older you are, the more (good and bad) financial baggage you're likely to bring to the partnership.

Next, from a banking standpoint, you’ll need to decide if you will be combining accounts or keeping them separate.Your financial adviser can walk you through how to combine your individual checking, savings, and money market accounts. He or she can also advise you about adding or changing beneficiaries on your individual retirement accounts and other retirement plans. Even if you decide to maintain separate accounts, it may be helpful to have at least one joint account to pay for shared expenses, such as mortgage or car payments, rent, household expenses, and insurance premiums. This account is meant strictly for household needs, and it allows you both to keep track of how you are spending money. A joint account can also help avoid complications in the event a spouse dies. When there are separate accounts and a spouse or common-law partner dies, the survivor will be excluded from the separate accounts if the estate goes into probate. A probate settlement could take months and add additional expenses due to court and attorney fees.

If you are both employed, you must take time to review and coordinate your employee benefits. You might save money by eliminating duplicate health care, for example. This process also allows you to determine, and then make any changes to, the beneficiary designations on retirement plans and insurance policies held through your employers.

Next, sit down and identify your financial goals as a couple

 Start by creating an annual budget, as well as a contingency plan in case a spouse gets laid off or becomes disabled. Make sure you have an emergency cash reserve equal to several months of income. Designate who will be responsible for paying the bills. Also look beyond your current financial situation. For example, discuss what you envision retirement will look like, and whether your current retirement account contributions are sufficient to achieve your long-term goals.

People who have been previously married may bring additional financial complications to the table, especially if they have children and/or are required to pay alimony, child support, or insurance premiums under the terms of a divorce settlement agreement. Also consider whether your remarriage will nullify any entitlements to assets from a former spouse. For example, getting remarried could invalidate your right to claim an inheritance or other financial interest. Meet with your advisers to address these issues whenever you are considering blending your finances.

Marriage is also a good time to meet with an estate planning attorney and get a plan in place. Estate planning is often pushed aside because it deals with a question most couples don’t want to discuss: “What happens if one of us dies?” However, it is important to have those conversations and formulate a plan. A will may be a good first step, or it may not be necessary depending on the type and value of the assets owned. An estate planning attorney will be able to provide specific guidance. Having health care and durable powers of attorney in place is always a smart idea in the event you are incapacitated. Depending on your assets, certain trusts may also play an important role in accomplishing your estate planning goals.

Remember that whether or not it's your first time down the aisle, marriage is a celebration. Don't let all the financial and administrative details that go along with your special day spoil it. Meet with your financial, tax, and legal advisers to establish a budget and tackle other financial and legal issues head-on. A little planning can alleviate potential stress well beyond your wedding day.

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"Remember that whether or not it's your first time down the aisle, marriage is a celebration. Don't let all the financial and administrative details that go along with your special day spoil it," writes Jeff Witz, CFP.

Alexander P. Kenigsberg, MD

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