Health Services Research

PV QA 3 - Poster Viewing Q&A 3

TU_38_2968 - Insurance Approval for Proton Therapy for Head and Neck Cancer: One Cancer Centers Experience

Tuesday, October 23
1:00 PM - 2:30 PM
Location: Innovation Hub, Exhibit Hall 3

Insurance Approval for Proton Therapy for Head and Neck Cancer: One Cancer Centers Experience
M. S. Ning1, D. R. Gomez2, E. D. Brooks2, C. Kim3, M. B. Palmer4, A. K. Shah5, J. Phan6, H. D. Skinner7, D. I. Rosenthal2, A. S. Garden2, W. H. Morrison2, C. D. Fuller8, J. Reddy6, K. M. Christopherson9, S. J. Frank2, and G. B. Gunn2; 1MD Anderson Cancer Center, Houston, TX, 2The University of Texas MD Anderson Cancer Center, Houston, TX, 3Department of Genetics, The University of Texas MD Anderson Cancer Center, Houston, TX, 4MD Anderson Proton Therapy Center, Houston, TX, 5MDACC, Houston, TX, 6Dept. of Radiation Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, 7Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, TX, 8University of Texas Graduate School of Biomedical Sciences, Houston, TX, 9UT MD Anderson Cancer Center, Houston, FL

Purpose/Objective(s): Given the potential for insurance approval to be a barrier to access to proton therapy (PT) for patients (pts) with head and neck cancer (HNC), this study was conducted to characterize the recent insurance approval/appeal outcomes at our institution.

Materials/Methods: Our database was queried for the number of HNC pts entering the insurance authorization process for PT; subsequent rates and time to insurance approval and successful overturn of denial on appeal were calculated. Clinical factors evaluated for association with approval on initial request were: site, insurance, year, and # of fractions. In addition, factors evaluated for association with successful appeal were: age, sex, ECOG, treatment intent (definitive vs. adjuvant), prior radiation, stage, dose, and PT technique (scanning vs. passive). Impact of comparative plans (IMRT vs. PT) submitted as part of the appeal process was analyzed, including presence of dosimetric advantage for specified OARs (parotid, cochlea, larynx, brainstem, spinal cord) defined as an improvement of ≥10% of the max or mean clinical dose constraint.

Results: From 01/13-12/16, the insurance authorization process was initiated for 350 pts with HNC; 130 had Medicare and 220 managed care/commercial insurance (MC). The number of pts with Medicare and MC who received insurance approval on initial request were 122 (94%) and 63 (27%), with median time from inquiry to decision of 6 (interquartile range [IQR]: 15) and 14 calendar days (IQR: 11), respectively. Of the 165 who were denied on initial request, an appeal process was initiated for 155 (94%), and of these, 109 (70%) had successful overturn of denial, with median time from inquiry to ultimate decision of 26 calendar days (IQR: 25). On univariate analysis (n=350), base of skull (OR 5.22, p=.027), Medicare (OR 12.53, p<.001), secondary insurance (OR 10.44, p<.001), and # of fractions (<33; OR 2.70, p=.0490) were associated with approval on initial request. However, on multivariable analysis (MVA) only Medicare (OR 6.86, p=.014) remained significant. For pts entering the appeal process (n=155), MVA found a decreased likelihood of approval with definitive intent (vs. adjuvant) (OR .25, p=.031) and submission of comparative plans (OR .202, p<.001). Of the 35 for whom a comparative plan was submitted, only 16 (46%) had a successful overturn of denial, and the presence of a dosimetric advantage for PT plans for the OARs tested was not associated with overturn of denial.

Conclusion: These single institution results inform patients, physicians, policy makers and insurers and highlight the need for insurers to greatly reduce the time to approval to ensure more timely access to PT, particularly for those in an insurance appeal process. The negative correlation of submission of a comparative plan with overturn of denial, despite dosimetric advantage for the OARs tested, and lack of distinct clinical correlates of approval, suggest that the insurance approval/appeal process is arbitrary and in need of reform.

Author Disclosure: M.S. Ning: None. D.R. Gomez: Research Grant; Merck, AstraZeneca. Honoraria; BMS. Speaker's Bureau; Merck, Varian. Advisory Board; AstraZeneca. E.D. Brooks: None. C. Kim: None. M.B. Palmer: Chief Operating Officer; UT MD Anderson Cancer Center Proton Therapy Center. A.K. Shah: Chief Healthcare Value Officer; UT MD Anderson Cancer Center Proton Therapy Center. J. Phan: None. H.D. Skinner: None. D.I. Rosenthal: Advisory Board; BMS. W.H. Morrison: Advisory Board; Regeneron. Stock; Merck, Baxter, Johnson and Johnson. Member; NCCN Nonmelanoma Skin and Merkel Cell Committees. C.D. Fuller: Research Grant; National Institutes of Health, National Science Foundation, Elekta AB. Grant funding; Elekta AB. Honoraria; Nederlandse Organisatie voor Wetenschappelijk Onde. Consultant; Elekta AB, Nederlandse Organisatie voor Wetenschappelijk Onde. Travel Expenses; Elekta AB, Nederlandse Organisatie voor Wetenschappelijk Onde. Reviewer; Radiological Society of North America. Associate Editor; Radiographics. Data Management Task Force Committee Member; MR-LinAc Consortium. Member; National Cancer Institute. Task Group Member; American Association of Physicists in Medicine. J. Reddy: None. K.M. Christopherson: None. S.J. Frank: Research Grant; C4 Imaging, ELEKTA, U19. Founder and Director; C4 Imaging. Honoraria; ELEKTA, Varian Medican Systems, Inc. Advisory Board; Varian Medican Systems, Inc. Stock; C4 Imaging. Royalty; C4 Imaging. Patent/License Fees/Copyright; C4 Imaging. Chairman; American Brachytherapy Society. Director; C4 Imaging. Director-at-large; North America Skull Base Society. G.B. Gunn: Associate Medical Director; UT MD Anderson Cancer Center Proton Therapy Center.

Eric Brooks, MD, MS

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