Digital Health Innovation and Informatics

PV QA 2 - Poster Viewing Q&A 2

MO_18_2790 - Trends in insurance coverage of proton therapy for Hodgkin lymphoma involving the thorax

Monday, October 22
10:45 AM - 12:15 PM
Location: Innovation Hub, Exhibit Hall 3

Trends in insurance coverage of proton therapy for Hodgkin lymphoma involving the thorax
S. R. W. Nurkic1, N. P. Mendenhall1, and B. S. Hoppe2; 1Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, 2Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL

Purpose/Objective(s): Proton therapy (PT) is more expensive than standard photon therapy, which makes obtaining insurance coverage difficult. In 2012, after several dosimetric studies demonstrated reduced radiation dose to OARs, the NCCN Hodgkin lymphoma (HL) guidelines began to endorse use of PT when clinically and dosimetrically indicated. This study investigates patterns of insurance coverage for thoracic HL (tHL) and the impact of NCCN’s endorsement on insurance coverage.

Materials/Methods: Following IRB approval (HLX-10), we reviewed insurance coverage for PT for 90 patients (56 women) with tHL treated at our center between 2007 and 2017. Of the 90 patients, 2 were ultimately treated with photons and 88 with PT. Thirty-three patients (37%) were pediatric (< 18 yrs), 47 (52%) young adults (18 to 40 yrs), and 10 (11%) adults (>40 yrs). Twenty-one (23%) were treated before 2012, 69 (77%) were treated in 2012 or later. Factors associated with insurance coverage were evaluated by a chi-square test.

Results: Among 90 patients reviewed, 7 had state Medicaid, 81 had private insurance, and 2 were uninsured. Fifty-seven patients (63%) were covered upfront without appeal. Among the 31 patients with insurance who were not initially approved upfront 18 (36%) were denied, including 14 with no appeals and 4 after multiple appeals. Of the remaining 13, 2 were approved after one appeal, 9 were approved after multiple appeals including 4 who were approved only after treatment started, and 2 were approved but insurance never paid. Two patients, ages 46 and 52 yrs, not covered by insurance were treated with photon therapy. Patients not covered by insurance and treated with PT were funded through institutional support. No patient paid out of pocket for PT. Insurance approval of PT significantly improved in 2012 and later (p<0.05). After 2012, 67% of patients were approved for PT without insurance appeal compared to 43% of patients treated prior to 2012. Increasing approval for upfront PT was seen across pediatric and young adult patients. In pediatric patients, 93% were covered without an appeal beginning in 2012, compared to 50% prior. For young adults, 57% were approved in 2012 compared to 22% prior. For adults treated after 2012, 33% were denied proton radiotherapy and treated with photon therapy, 50% were approved without appeal, and 17% were approved only after treatment completion.

Conclusion: Limited to patients treated at our facility, insurance coverage of PT for tHL has improved since endorsement of PT by the NCCN in 2012; however, this improvement is not consistent among age groups. Denials are still common, especially among adults and young adults. Multiple appeals following denials can lead to successful coverage for several patients, but this process can take months, impacting patient’s treatment decisions. Insurance companies should continue to revisit their policies and consider proton therapy based on expert endorsement.

Author Disclosure: S.R. Nurkic: None. N.P. Mendenhall: None. B.S. Hoppe: Advisory Board; Proton Collaborative Group. Travel Expenses; Children Oncology Group. see below; Proton Collaborative Group. Co-Chair of RTOG 1308; RTOG. Member of the Lymphoma Sub-committee; American College of Radiology.

Sommer Nurkic, MD, MPH

Presentation(s):

Send Email for Sommer Nurkic


Assets

MO_18_2790 - Trends in insurance coverage of proton therapy for Hodgkin lymphoma involving the thorax



Attendees who have favorited this

Please enter your access key

The asset you are trying to access is locked. Please enter your access key to unlock.

Send Email for Trends in insurance coverage of proton therapy for Hodgkin lymphoma involving the thorax