Health Services Research

PV QA 3 - Poster Viewing Q&A 3

TU_41_3005 - Insurance Coverage Approval Delay Among Patients Receiving Proton Radiation Therapy

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

Insurance Coverage Approval Delay Among Patients Receiving Proton Radiation Therapy
R. Sethi1, N. Horick1, B. Y. Yeap2, A. McKay1, J. Depina1, S. I. Goldberg3, R. Miao1, H. A. Shih4, T. F. DeLaney3, S. MacDonald3, and Y. L. E. Chen3; 1Massachusetts General Hospital, Boston, MA, 2Department of Medicine, Massachusetts General Hospital and Harvard Medical School, Boston, MA, 3Department of Radiation Oncology, Massachusetts General Hospital, Boston, MA, 4Department of Radiation Oncology, Massachusetts General Hospital, Harvard Medical School, Boston, MA

Purpose/Objective(s): A significant clinical and administrative effort is required by most proton centers to coordinate insurance approval for patients. Many patients with malignancies where protons offer dosimetric advantage, such as medulloblastoma and sarcoma, require radiation therapy within a particular time range. The extent of coverage and average time for coverage decisions has not been studied.

Materials/Methods: As part of an IRB approved institutional proton cohort registry, data was both retrospectively and prospectively gathered on dates of insurance submission and decision for patients of all ages at our Hospital and Proton Center between April 2016 and June 2017 (14 months). Factors associated with approval were analyzed.

Results: Over the timeframe, 612 submissions for insurance coverage were made. Sites included 554 (91%) adult and 58 (9%) pediatric patients (age≤21y at the time of insurance submission). The median time to decision was 6 days (0 to 158) for approved patients, and 39 days (range, 5 to 374) for denied patients (p<0.0001 via Wilcoxon rank-sum test). Among all patients, 49 (8%) of patients had a delay over 30 days, including 19 (3%) who had a delay over 60 days. The overall rate of insurance approval was 94% for all patients. Approval rate did not vary significantly by cancer site (p=0.15), age (p=0.15), and type of insurance (p=0.42). 9 (1.5%) patients self-funded their treatment. Overall, 292 (51%) of all patients ultimately received a median of 12 fractions (1 to 38) of proton radiation.

Conclusion: Patients denied proton treatment face significant delay in time to eventual start of treatment with photons. This may have a critical effect in malignancies where radiation is time sensitive. This study may significantly overestimate the rate of insurance approval given provider self-selection to avoid plans that routinely reject protons. Table 1: Variables associated with insurance approval time
Variable N= 612
Site (Adult only)
Head and neck 56 (10%)
CNS 206 (37%)
Lung 32 (6%)
Sarcoma 94 (17%)
Breast 39 (7%)
GU 35 (6%)
GI 73 (13%)
Heme 6 (1%)
Other 6 (1%)
Site (Peds only – age≤21y)
Head and neck 1 (2%)
CNS 43 (74%)
Sarcoma 11 (18%)
GI 1 (2%)
Heme 1 (2%)
Other 1 (2%)
Percentage of Insurance Approval by Age
Adults 98%
Peds 94%
Percentage of Insurance Approval by Site
Head and neck 95%
CNS 93%
Lung 97%
Sarcoma 95%
Breast 82%
GU 97%
GI 97%
Heme 86%
Median time (and range) from Submission to Insurance Decision by Age
Adults 7 days (0 to 374)
Peds 6 days (0 to 58)
Median time from Submission to Insurance Decision by Site
Head and neck 8 days (0 to 115)
CNS 6 days (0 to 158)
Lung 7 days (0 to 25)
Sarcoma 8 days (0 to 69)
Breast 8 days (0 to 98)
GU 5 days (0 to 59)
GI 5 days (0 to 374)
Heme 5 days (3 to 45)
Median time from Submission to Insurance Decision by Insurance Type
Medicare/Medicaid 3 days (0 to 374)
Private Insurance 7 days (0 to 158)
International 2 days (0 to 35)
Time from Submission to Treatment Start (Proton or Photon)
Median 39 days (2 to 402)
Delayed >30 days 321 (58%)
Delayed >60 days 170 (31%)

Author Disclosure: R. Sethi: None. N. Horick: None. S.I. Goldberg: None. H.A. Shih: Employee; Dartmouth Hitchcock. Honoraria; UpToDate. Chief, CNS & Eye Radiat Oncol Services; Massachusetts General Hospital. Associate Medical Director; MGH Proton Therapy Center. Associate Director; Harvard Radiation Oncology Program. T.F. DeLaney: None. Y.E. Chen: Employee; Beth Israel Deaconess Medical Center.

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