Abstract
PurposeTo determine factors that influence insurance approval for definitive proton therapy (PT) for prostate cancer.Materials and MethodsBetween 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).ResultsOn 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).ConclusionProton 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.
Highlights
Definitive proton therapy (PT) is an excellent treatment option for patients with localized prostate cancer
Given that many PT centers treat patients with prostate cancer, and the few reports on PT approval for prostate cancer, this study aimed to identify factors affecting the likelihood of insurance approval for definitive prostate PT at the University of Florida Health Proton Therapy Institute (UFHPTI)
Of the 329 patients whose insurance did not cover PT, approval was obtained for 160 patients (48.6%)
Summary
Definitive proton therapy (PT) is an excellent treatment option for patients with localized prostate cancer. Up to 2 in 3 patients—the majority—will achieve PT approval, but only after appealing and proceeding through the highly restrictive and lengthy insurance denial-overturn process, which differs, depending on the payor [7]. This burden and barrier to care has led some PT centers to strategically redesign operations and devote substantial resources to addressing PA to ensure timely access to appropriate care [10]. During PA or other appeals processes, patients are put in positions in which delays in approval may lead to compromised outcomes, including those patients facing prostate cancer
Sign-in/Register to view highlights & summary Sign-in/Register to access full text options 
Free) 
Talk to us
Join us for a 30 min session where you can share your feedback and ask us any queries you have
Schedule a call
