Proton Therapy Insurance Coverage: Fair or Foul?

Nick Mulcahy

August 09, 2017

Are a group of patients and physicians at the Roberts Proton Therapy Center of the University of Pennsylvania in Philadelphia being treated appropriately and efficiently by insurance companies?

That question is at the heart of a new study by two radiation oncologists at the proton center, Eric Ojerholm, MD, and Christine Hill-Kayser, MD.

Their new article suggests the answer is no.

The process by which a denial of coverage is appealed, which in their study took a median of 7.5 days, is stressful and inefficient and ought to be "streamlined," say the pair. Their findings were published online August 7 in Pediatric Blood and Cancer.

However, another expert thinks that this issue needs context.

"It must be nice to be able to spend a $100 million dollars on a new medical technology and bill for it without having to prove its superiority to cheaper alternatives in randomized trials," said Vinay Prasad, MD, of the Knight Cancer Institute at the Oregon Health and Sciences Center in Portland.

Dr Prasad is referring to the fact that in the United States, the use of proton therapy to treat cancer has been highly controversial, because it is very expensive and is not supported by level-one evidence.

He suggested that insurance companies may have good reason to deny some claims.

Indeed, to date, only one randomized clinical trial (in lung cancer) has final efficacy results. In that trial, proton therapy was not found to be more effective than standard radiotherapy, as reported by Medscape Medical News.

In the new study, Dr Ojerholm and Dr Hill-Kayser report that from 2010 to 2015, a total of 255 (89%) of a set of 287 cancer cases were initially approved for proton treatment at their center. In only 32 (11%) cases was proton therapy denied.

Notably, almost all of the denied cases were approved upon appeal. In the end, 286 of the 287 cases were treated with proton therapy and were covered by insurance.

The cases were a mix of primary tumors of the central nervous system (CNS) (59% of the total, the most common of which were medulloblastoma and ependymoma), non-CNS solid tumors (29%, most commonly, sarcoma and neuroblastoma), and non-CNS lymphomas (12%, most commonly, Hodgkin lymphoma).

The majority of patients (88%) were younger than 18 years; the remaining 12% were aged 19 to 30 years. However, all of the cases were classified as pediatric primary tumors, because these tumors "are generally judged to be pediatric in nature," write the study authors.

For cases in which insurance coverage was denied, the appeals process took a median of 7.5 days and involved letters (13%), peer-to-peer telephone calls (56%), or both (31%).

Dr Ojerholm told Medscape Medical News that denials are taxing: "Patients and families know that their doctor has recommended proton therapy as the best treatment, so it can be quite stressful after an initial denial."

The appeals process needs fixing, he argued.

"If the ultimate outcome is approval in nearly every case," he and Dr Hill-Kayser write, "then we believe the process should be simplified."

We believe the process should be simplified. Dr E. Ojerholm and Dr C. Hill-Kayser

Streamlined approval, they say, would "eliminate delays for patients and reduce the appeals burden for both providers and payers." To that end, insurers should modify policy language to explicitly denote coverage for pediatric cancer cases or create special pediatric forms or codes for this patient population.

Dr Prasad thinks the authors are missing the message.

"The purpose [of coverage denial] is that it makes your life difficult so that in the future you are less likely to recommend it unless you have very good reason," he told Medscape Medical News.

But there is reason, suggest the study authors.

They say all their proton therapy patients must be judged medically appropriate by their institution's Pediatric Proton Triage Committee, a multidisciplinary group of pediatric specialists comprising radiation oncologists, medical oncologists, radiologists, and oncology nurses.

Furthermore, proton therapy "offers dosimetric advantages over photon radiotherapy in many cases," they say.

The "strongest evidence" for pediatric proton therapy is in brain and spine tumors, which is what many of these cases were, said Dr Ojerholm in a press statement.

He also said that the "typical cost" is about $66,000 for their pediatric proton patients (referring to J Am Coll Radiol. 2014;11:995-997).

The study authors conclude that top-level evidence may never come: "There are no randomized trials comparing PBT [proton beam therapy] to photons for pediatric cancer patients, and none may ever exist."

Nonsense, said Dr Prasad.

Imagine if several centers all got together and decided — this may sound crazy ― to work together. Dr Vinay Prasad

"In just 5 years, from 2010-2015, at just one hospital with a proton beam (Penn), 287 patients were treated with protons. Wow! Just one center was able to get a critical mass of patients needing proton therapy. Imagine if several centers all got together and decided — this may sound crazy ― to work together. Perhaps they could pool these patients and conduct a randomized trial so that patients with these rare conditions can finally know if protons are superior to photons," he said.

"Despite what many believe, this remains an assumption that has not been validated," he added.

The authors and Dr Prasad have disclosed no relevant financial relationships.

Pediatr Blood. Published online August 7, 2017. Abstract

Follow Medscape senior journalist Nick Mulcahy on Twitter: @MulcahyNick

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