Insurance Coverage Decisions for Pediatric Proton Therapy

Abstract

A growing body of literature supports benefits of proton therapy over photon therapy for normal tissue sparing in pediatric patients; however, high-level comparative clinical evidence is lacking. As such, proton therapy is not described as medically necessary for pediatric cancers within the coverage policies of several major US insurance companies. Other policies allow protons only for specific types of pediatric tumors or employ arbitrary age cutoffs. We examined real-world coverage decisions at a proton facility with a busy pediatric practice. We reviewed the billing office records of patients judged medically appropriate for protons by our institutional Pediatric Proton Triage Committee from 2010-2015. We included all patients ≤ 18 years old or those aged 19-30 with a pediatric primary tumor. We excluded international patients, cases without complete billing records, or patients who did not ultimately receive treatment at our institution for reasons unrelated to insurance. We tested the null hypothesis that insurance decision was unrelated to age or tumor category using Fisher’s exact test. There were 377 eligible patients with CNS malignancies (60%), non-CNS solid tumors (28%), or non-CNS lymphomas (12%). Twelve percent were over age 18, and nearly all cases (98%) were treated with curative intent. From the total cohort, 287 patients (76%) were required by their insurance companies to receive proton preauthorization or were issued an upfront predetermination/precertification. That initial decision—rendered in a median 4 days (IQR 1-7)—was approval for protons in 255 cases (89%), and denial in 32 cases (11%). The denial rate was 5% for CNS tumors, 15% for non-CNS solid tumors, and 29% for non-CNS lymphomas (P < 0.001). The denial rate was 9% for patients ≤ 18 years old versus 26% for patients aged 19-30 (P= 0.008). Of 32 cases originally denied, 31 (97%) were ultimately overturned via appeal. The appeal process required a median 7 additional days (IQR 3-15) and involved letters (13%), peer-to-peer phone calls (61%) or both (26%). Ultimately, >99% of cases were approved for protons. The single case exhausting all appeals and ultimately denied was an 18 year old with stage IIIB Hodgkin lymphoma. Insurance coverage of proton therapy was initially denied for ∼10% of pediatric patients, and this was significantly more common for non-CNS tumors and patients over 18 years old. The appeal process added an additional week of delay and nearly all denials were overturned. Despite unfavorable language in many insurance coverage policies, real-world decisions were eventual approval in > 99% of cases. Insurance companies appear to have largely accepted the current level of evidence for protons in pediatric patients, but significant time and resources are spent on appeal processes.