Insurance Approval for Proton Beam Therapy and its Impact on Delays in Treatment

Gupta, Apar; Khan, Atif J.; Goyal, Sharad; Millevoi, Rihan; Elsebai, Natalia; Jabbour, Salma K.; Yue, Ning J.; Haffty, Bruce G.; Parikh, Rahul R.

doi:10.1016/j.ijrobp.2018.12.021

Cited by 46 publications

(54 citation statements)

References 14 publications

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“…Additionally, this was a single-institutional analysis in a metropolitan area, which may limit the generalizability of our experience to other centers. Nevertheless, our results mirror other published experiences which suggests that there may be some general applicability to other centers across the country (43,49).…”

Section: Discussionsupporting

confidence: 90%

“…Our results are in line with recently published experiences from MD Anderson where a significant number of patients were denied PBT coverage by private insurance with a subsequent approval process that required a similar significant time and resource investment from the radiation department (42). The appeal process, as demonstrated by other institutions, also leads to significant delays to the start of proton treatment, with adult patients waiting an average of one month (42,43). Treatment delays have been previously demonstrated across various subsites to be detrimental to patient outcomes, including for gynecologic cancers and tumors of the head and neck (44)(45)(46).…”

Section: Discussionsupporting

confidence: 87%

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Early Experience of the World’s First Single-Room Gantry Mounted Active Scanning Proton Therapy System at an Integrated Cancer Center

Forsthoefel

Ballew

Unger

et al. 2020

Preprint

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Introduction Review the early experience with a single-room gantry mounted active scanning proton therapy system implemented in the modern era. Materials and Methods All patients treated with proton beam radiotherapy (PBT) were enrolled in an institutional review board-approved patient registry. Proton beam radiotherapy was delivered with a 250 MeV gantry mounted synchrocyclotron in a single-room integrated facility within the pre-existing cancer center. Demographic data, cancer diagnoses, treatment technique, and geographic patterns were obtained for all patients. Treatment plans were evaluated for mixed modality therapy. Insurance approval data was collected for all patients treated with PBT. Results A total of 132 patients were treated with PBT between March 2018 and June 2019. The most common oncologic subsites treated included the central nervous system (22%), gastrointestinal tract (20%), and genitourinary tract (20%). The most common histologies treated included prostate adenocarcinoma (19%), non-small cell lung cancer (10%), primary CNS gliomas (8%), and esophageal cancer (8%). Rationale for PBT treatment included limitation of dose to adjacent critical organs at risk (67%), reirradiation (19%), and patient comorbidities (11%). Patients received at least one x-ray fraction delivered as prescribed (36%) or less commonly due to unplanned machine downtime (34%). Concurrent systemic therapy was administered to 57 patients (43%). Twenty-six patients (20%) were initially denied insurance coverage and required peer-to-peers (65%), written appeals (12%), secondary insurance approval (12%), and comparison x-ray to proton plans (8%) for subsequent approval. Proton beam radiotherapy approval required a median of 17 days from insurance submission. Conclusion Incorporation of PBT into our existing cancer center allowed for multidisciplinary oncologic treatment of a diverse population of patients. Insurance coverage for PBT presents as a significant hurdle and improvements are needed to provide more timely access to necessary oncologic care.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionsupporting

confidence: 87%

Early Experience of the World’s First Single-Room Gantry Mounted Active Scanning Proton Therapy System at an Integrated Cancer Center

Forsthoefel

Ballew

Unger

et al. 2020

Preprint

View full text Add to dashboard Cite

show abstract

“…Our results are in line with recently published experiences from MD Anderson where a significant number of patients were denied PBT coverage by private insurance with a subsequent approval process that required a similar significant time and resource investment from the radiation department (46). The appeal process, as demonstrated by other institutions, also leads to significant delays to the start of proton treatment, with adult patients waiting an average of 1 month (46,47). Treatment delays have been previously demonstrated across various subsites to be detrimental to patient outcomes, including for gynecologic cancers and tumors of the head and neck (48)(49)(50).…”

Section: Discussionsupporting

confidence: 87%

Early Experience of the First Single-Room Gantry Mounted Active Scanning Proton Therapy System at an Integrated Cancer Center

et al. 2020

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Introduction: Review the early experience with a single-room gantry mounted active scanning proton therapy system. Material and Methods: All patients treated with proton beam radiotherapy (PBT) were enrolled in an institutional review board-approved patient registry. Proton beam radiotherapy was delivered with a 250 MeV gantry mounted synchrocyclotron in a single-room integrated facility within the pre-existing cancer center. Demographic data, cancer diagnoses, treatment technique, and geographic patterns were obtained for all patients. Treatment plans were evaluated for mixed modality therapy. Insurance approval data was collected for all patients treated with PBT. Results: A total of 132 patients were treated with PBT between March 2018 and June 2019. The most common oncologic subsites treated included the central nervous system (22%), gastrointestinal tract (20%), and genitourinary tract (20%). The most common histologies treated included prostate adenocarcinoma (19%), non-small cell lung cancer (10%), primary CNS gliomas (8%), and esophageal cancer (8%). Rationale for PBT treatment included limitation of dose to adjacent critical organs at risk (67%), reirradiation (19%), and patient comorbidities (11%). Patients received at least one x-ray fraction delivered as prescribed (36%) or less commonly due to unplanned machine downtime (34%). Concurrent systemic therapy was administered to 57 patients (43%). Twenty-six patients (20%) were initially denied insurance coverage and required peer-to-peers (65%), written appeals (12%), secondary insurance approval (12%), and comparison x-ray to proton plans (8%) for subsequent approval. Proton beam radiotherapy approval required a median of 17 days from insurance submission. Discussion: Incorporation of PBT into our existing cancer center allowed for multidisciplinary oncologic treatment of a diverse population of patients. Insurance coverage for PBT presents as a significant hurdle and improvements are needed to provide more timely access to necessary oncologic care.

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“…In a similar analysis of all patients considered for PBT between 2015 and 2018 at the Rutgers Cancer Institute of New Jersey, the initial denial rate was 64%. 5 After the appeals process (average time 22.5 days overall; 33.8 days…”

Section: A Significant Barrier To Patient Carementioning

confidence: 99%

“…8 However, the 2 referenced studies demonstrate a clear unwillingness on the commercial payers' part to support fair evaluation of the relative merits of PBT through patient enrollment on phase 3 trials. 4,5 Others have developed pragmatic models to objectify the benefit of PBT in terms of toxicity profile at the individual patient level. 9 This single-index measurement for demonstrating the potential amount of toxicity reduction using PBT when compared with conventional photon-based RT has been recognized by the Health Insurance Board in the Netherlands to determine patient selection and reimbursement for PBT.…”

Section: Proton Beam Therapy At the Mayo Clinic And The University Ofmentioning

confidence: 99%

The Insurance Approval Process for Proton Beam Therapy Must Change: Prior Authorization Is Crippling Access to Appropriate Health Care

Sio

Mohindra

Regine

et al. 2019

International Journal of Radiation Oncology*Biology*Physics

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With almost 70 proton beam therapy (PBT) centers worldwide, of which 29 are operating in the US, and multiple centers under construction, 1 it is increasingly important that the insurance coverage process for PBT is standardized to allow seamless approval, minimizing delays and the burden on patients and providers. With over 30 years of the US Food and Drug Administrationeapproved practice and research, 2 PBT is not "experimental" or "investigational"; however, these terms are still commonly used in denial letters that are written by private insurance payers and thirdparty organizations that claim to provide medical benefit "management and solutions." The basis for their coverage and the evidence cited in their policies are often out of date and not peer reviewed by clinical experts in the field.

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Insurance Approval for Proton Beam Therapy and its Impact on Delays in Treatment

Cited by 46 publications

References 14 publications

Early Experience of the World’s First Single-Room Gantry Mounted Active Scanning Proton Therapy System at an Integrated Cancer Center

Early Experience of the World’s First Single-Room Gantry Mounted Active Scanning Proton Therapy System at an Integrated Cancer Center

Early Experience of the First Single-Room Gantry Mounted Active Scanning Proton Therapy System at an Integrated Cancer Center

The Insurance Approval Process for Proton Beam Therapy Must Change: Prior Authorization Is Crippling Access to Appropriate Health Care

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