Majority of Insurance Coverage Denials for Pediatric Proton Therapy Approved on Appeal

Although a lack of trial data for proton beam therapy (PBT) in pediatric patients pose a challenge for insurance companies, new findings reveal 97% of cases originally denied were treated after the decisions were appealed.

In a study published in Pediatric Blood & Cancer, investigators examined insurance coverage decisions between 2010 and 2015 at the Penn’s Roberts Proton Therapy Center.

“Most oncologists agree it’s a better choice than traditional radiation in pediatric cases because it’s so targeted,” said co-author Eric Ojerholm, MD. “However, since we don’t have data from randomized clinical trials with these patients, we don’t have the conclusive evidence that insurance companies normally like to see before universally approving coverage.”

Of the 287 evaluated cases, 89% were approved outright for PBT and 11% were initially denied. Furthermore, 31 of 32 cases that were initially denied were overturned and approved on appeal.

Despite unfavorable language in coverage policies of PBT, real-world decisions were eventually approved in 97% of cases.

“This shows that insurers are ultimately willing to accept the benefits of proton therapy for young cancer patients, however a great deal of time and resources are still wasted in appeals of coverage denials and ultimate approvals,” said co-author Christine Hill-Kayser, MD.

Both age and tumor type were found to be most associated with initial denial. Some patients older than 18 years develop a cancer considered to be pediatric because of how the tumor behaves, such as neuroblastoma, rhabdomyosarcoma, germinoma, and Ewing sarcoma.

Patients older than 18 years with these forms of cancer would typically be treated the same way a pediatric patient is, yet patients in this group were initially denied 4 times more often as those 18 years or younger, according to the study.

The investigators also observed that cancers located outside the brain or spine were denied 4.5 times more often.

“This is probably because the strongest evidence for pediatric proton therapy is in brain and spine tumors,” Ojerholm said. “Insurers appear willing to accept these cases but may initially be more hesitant for other disease sites.”

Although the appeal rates for PBT are high, the process itself can pose a challenge, requiring letters, peer-to-peer phone calls, or both. This process often delayed care by an average of a week or more. In fact, it took multiple rounds of appeal before gaining approval in 28% of cases.

“These appeals mean time and resources for patients, doctors, and insurers, “Hill-Kayser said. “If the ultimate outcome is overwhelmingly going to be approval anyway, we believe there should be a way to streamline this process.”

The authors highlighted some suggestions to streamline the process, such as altering insurance policy language to recognize the distinction of pediatric tumors and classifying patients aged 19 to 30 who have pediatric cancers as pediatric cases.

“Payers appear to have largely accepted the current level-of-evidence for pediatric PBT, but all parties spend significant time and resources on appeals,” the authors concluded. “Streamlined approval processes could align incentives among stakeholders.”

Some limitations to the study were all data came from a single hospital, and Penn has an advisory board that evaluates patients for PBT and only recommends those likely to benefit from treatment the most, meaning if other centers skip that step, they could see more denials or less appeal reversals.