TY - JOUR
T1 - Commercial Insurance Coverage of Advanced Radiation Therapy Techniques Compared With American Society for Radiation Oncology Model Policies
AU - Verma, Vivek
AU - Ludmir, Ethan B.
AU - Mesko, Shane M.
AU - Brooks, Eric D.
AU - Augustyn, Alexander
AU - Milano, Michael T.
AU - Lin, Steven H.
AU - Chang, Joe Y.
AU - Welsh, James W.
N1 - Funding Information:
Disclosures: This work has never been presented or published before in any form. James W. Welsh reports research support from GlaxoSmithKline, Bristol-Meyers Squibb, Merck, Nanobiotix, Mavu Pharma, and Checkmate Pharmaceuticals and serves on the scientific advisory board of RefleXion Medical, MolecularMatch, OncoResponse, CheckMate, Mavu Pharmaceuticals, and Alpine Immune Sciences. In addition, Dr. Welsh is the cofounder of Helios Oncology, MolecularMatch, and OncoResponse and serves as an advisor to Astra Zeneca, Merck, MolecularMatch, Incyte, Aileron, and Nanobiotix. Dr. Welsh also holds the following patents: MP470 (amuvatinib), MRX34 regulation of PDL1, and XRT technique to overcome immune resistance. Joe Y. Chang has received honoraria from Varian and AstraZeneca, research grants from Bristol-Myers Squibb, and is a shareholder of Global Oncology One. Steven H. Lin has received research funding from Elekta, STCube Pharmaceuticals, Peregrine, Hitachi Chemical Inc, and Roche/Genentech, has served as a consultant for AstraZeneca, and received honoraria from US Oncology and ProCure. Shane M. Mesko is a consultant for Oscar Health. All other authors declare that conflicts of interest do not exist. There was no research support for this study.
Funding Information:
Disclosures: This work has never been presented or published before in any form. James W. Welsh reports research support from GlaxoSmithKline, Bristol-Meyers Squibb, Merck, Nanobiotix, Mavu Pharma, and Checkmate Pharmaceuticals and serves on the scientific advisory board of RefleXion Medical, MolecularMatch, OncoResponse, CheckMate, Mavu Pharmaceuticals, and Alpine Immune Sciences. In addition, Dr. Welsh is the cofounder of Helios Oncology, MolecularMatch, and OncoResponse and serves as an advisor to Astra Zeneca, Merck, MolecularMatch, Incyte, Aileron, and Nanobiotix. Dr. Welsh also holds the following patents: MP470 (amuvatinib), MRX34 regulation of PDL1, and XRT technique to overcome immune resistance. Joe Y. Chang has received honoraria from Varian and AstraZeneca, research grants from Bristol-Myers Squibb, and is a shareholder of Global Oncology One. Steven H. Lin has received research funding from Elekta, STCube Pharmaceuticals, Peregrine, Hitachi Chemical Inc, and Roche/Genentech, has served as a consultant for AstraZeneca, and received honoraria from US Oncology and ProCure. Shane M. Mesko is a consultant for Oscar Health. All other authors declare that conflicts of interest do not exist. There was no research support for this study. Basic Original Report
Publisher Copyright:
© 2019 American Society for Radiation Oncology
PY - 2020/9/1
Y1 - 2020/9/1
N2 - Purpose: This study aimed to compare and contrast the American Society for Radiation Oncology (ASTRO) model policies (MPs) for intensity modulated radiation therapy (IMRT), stereotactic radiosurgery (SRS), stereotactic ablative radiation therapy (SABR), and proton beam therapy (PBT) with the coverage policies constructed by 5 of the largest publicly available commercial insurers throughout the United States (ie, Aetna, Anthem, Cigna, Humana, and United Healthcare). Methods and Materials: Appropriate indications for IMRT, SRS, SABR, and PBT by disease site (and particular clinical setting thereof) were extracted from the most recently published ASTRO MPs and published coverage policies (2019 editions) of the 5 carriers. After tabulation, concordance between ASTRO MPs and insurance policies were calculated for each modality. Results: All 5 insurer policies supported IMRT for neoplasms of the central nervous system, head/neck, hepatopancreaticobiliary, anal, and prostate cancers. The least covered diseases were retroperitoneal tumors (n = 0 carriers) and bladder cancer (n = 1). For SRS, all carriers covered benign brain tumors, brain metastases, arteriovenous malformations, and trigeminal neuralgia. None of the insurance carriers covered SRS for medically refractory epilepsy. For SABR, primary liver, lung, and low- or intermediate-risk prostate cancer were covered by all insurers, and none allowed SABR for primary biliary neoplasms. Only one insurance carrier each covered SABR for primary/metastatic adrenal disease and primary renal cancer. All carriers approved PBT for ocular melanoma, skull base tumors, and pediatric malignancies. The ASTRO MPs listed 4 PBT scenarios (ie, spinal disease, retroperitoneal sarcoma, head/neck neoplasms, and patients with genetic radiosensitivity syndromes) not covered by any insurer. Concordance between insurance carriers and ASTRO MPs was 67.8% for IMRT, 72.0% for SRS, 58.4% for SABR, and 41.8% for PBT (P =.005). Conclusions: Coverage guidelines for IMRT, SRS, SABR, and PBT vary across 5 major insurance providers and may be substantially discordant compared with ASTRO coverage guidelines. There remain several specific areas where ongoing and future dialogues between ASTRO members, payers, and policymakers remain essential.
AB - Purpose: This study aimed to compare and contrast the American Society for Radiation Oncology (ASTRO) model policies (MPs) for intensity modulated radiation therapy (IMRT), stereotactic radiosurgery (SRS), stereotactic ablative radiation therapy (SABR), and proton beam therapy (PBT) with the coverage policies constructed by 5 of the largest publicly available commercial insurers throughout the United States (ie, Aetna, Anthem, Cigna, Humana, and United Healthcare). Methods and Materials: Appropriate indications for IMRT, SRS, SABR, and PBT by disease site (and particular clinical setting thereof) were extracted from the most recently published ASTRO MPs and published coverage policies (2019 editions) of the 5 carriers. After tabulation, concordance between ASTRO MPs and insurance policies were calculated for each modality. Results: All 5 insurer policies supported IMRT for neoplasms of the central nervous system, head/neck, hepatopancreaticobiliary, anal, and prostate cancers. The least covered diseases were retroperitoneal tumors (n = 0 carriers) and bladder cancer (n = 1). For SRS, all carriers covered benign brain tumors, brain metastases, arteriovenous malformations, and trigeminal neuralgia. None of the insurance carriers covered SRS for medically refractory epilepsy. For SABR, primary liver, lung, and low- or intermediate-risk prostate cancer were covered by all insurers, and none allowed SABR for primary biliary neoplasms. Only one insurance carrier each covered SABR for primary/metastatic adrenal disease and primary renal cancer. All carriers approved PBT for ocular melanoma, skull base tumors, and pediatric malignancies. The ASTRO MPs listed 4 PBT scenarios (ie, spinal disease, retroperitoneal sarcoma, head/neck neoplasms, and patients with genetic radiosensitivity syndromes) not covered by any insurer. Concordance between insurance carriers and ASTRO MPs was 67.8% for IMRT, 72.0% for SRS, 58.4% for SABR, and 41.8% for PBT (P =.005). Conclusions: Coverage guidelines for IMRT, SRS, SABR, and PBT vary across 5 major insurance providers and may be substantially discordant compared with ASTRO coverage guidelines. There remain several specific areas where ongoing and future dialogues between ASTRO members, payers, and policymakers remain essential.
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U2 - 10.1016/j.prro.2019.08.005
DO - 10.1016/j.prro.2019.08.005
M3 - Article
C2 - 31446147
AN - SCOPUS:85072571946
SN - 1879-8500
VL - 10
SP - 324
EP - 329
JO - Practical radiation oncology
JF - Practical radiation oncology
IS - 5
ER -