ABSTRACT
PURPOSE: To determine factors that influence insurance approval for definitive proton therapy (PT) for prostate cancer. MATERIALS AND METHODS: Between 2014 and 2018, 1592 insured patients with localized prostate cancer were evaluated and recommended to undergo definitive PT; 547 patients (34.4%) had commercial insurance, whereas 1045 patients (65.6%) had Medicare/Medicaid. Of those with Medicare, 164 patients (15.7%) had Medicare alone; 677 (64.8%) had supplemental plans; and 204 (19.5%) had secondary commercial insurance. Insurance that "covered" PT for prostate cancer implied that it was an indication designated in the coverage policy. "Not covered" means that the insurance policy did not list prostate cancer as an indication for PT. Of all 1592 patients, 1263 (79.3%) belonged to plans that covered PT per policy. However, approval for PT was still required via medical review for 619 patients (38.9%), comparative dosimetry for 56 patients (3.5%), peer-to-peer discussion for 234 patients (14.7%), and administrative law judge hearings for 3 patients (<0.1%). Multivariate analyses of factors affecting approval were conducted, including risk group (low/intermediate versus high), insurance type (commercial versus Medicare/Medicaid), whether PT was included as a covered benefit under the plan (covered versus not covered), and time period (2014-16 versus 2017 versus 2018). RESULTS: On multivariate analysis, factors affecting PT approval for prostate treatment included coverage of PT per policy (97.1% had approval with insurance that covered PT versus 48.6% whose insurance did not cover PT; P < .001); insurance type (32.5% had approval with commercial insurance versus 97.4% with Medicare; P < .001); and time, with 877/987 patients (88.9%) approved between 2014 and 2016, 255/312 patients (81.7%) approved during 2017, and 255/293 patients (87.0%) approved thereafter (P = .02). Clinical factors, including risk group, had no bearing on insurance approval (P = .44). CONCLUSION: Proton insurance approval for prostate cancer has decreased, is most influenced by the type of insurance a patient belongs to, and is unrelated to clinical factors (risk group) in this study. More work is needed to help navigate appropriate access to care and to assist patients seeking definitive PT for prostate cancer treatment.
ABSTRACT
PURPOSE: To determine factors that influence insurance approval for breast cancer patients for whom adjuvant proton therapy (PT) is recommended. PATIENTS AND METHODS: We sought to identify factors associated with PT approval among 131 insured patients seen in consultation between 2014 and 2018 and recommended adjuvant PT. Insurance status included: commercial, 76 patients (58%); Medicare, 41 (31%); and Medicaid, 14 (11%). Ninety-six patients (73%) had policies that "covered" PT. Insurance "coverage" for PT was not associated with final approval nor was lack of "coverage" associated with denial despite additional steps of medical review, peer-to-peer discussion, patient appeal, and judicial review.In seeking approval, the following steps were required: medical review, 73 patients (56%); comparative dosimetry, 34 patients (26%); peer-to-peer discussion, 20 patients (15%); and administrative law judge, 1 patient (1%). A multivariate analysis of predictors for final insurance approval was conducted including the following covariates: T stage (Tis-T2 vs T3-T4); N stage (N0 vs N1-N3); laterality (left or bilateral vs right); insurance type (commercial vs Medicare/Medicaid) combined with potential insurance coverage (covered vs not covered); time period (2014-2016 vs 2017-2018); and age (<57 years vs 57 and older). RESULTS: Insurance approval was obtained for 93/96 patients (97%) with insurance that covered PT versus 23/35 patients (66%) whose insurance did not cover PT. Insurance approval stratified by insurance type and coverage was: commercial-covered, 52/52 patients (100%); Medicare or Medicaid-covered, 41/44 (93%); commercial-not covered, 16/22 (73%); and Medicare or Medicaid-not covered, 7/13 (54%).On multivariate analysis, factors impacting approval revealed T stage, p=0.3127; N stage, p=0.8524; laterality, p=0.1829; insurance type combined with potential coverage, p<0.0001; time period, p=0.2731; and age, p=0.6678. CONCLUSION: The only parameter that significantly influenced approval for treatment with PT was insurance type combined with potential coverage with ultimate approval rates ranging from 54% to 100%.
