Department of Radiation Oncology, Rutgers Cancer Institute of New Jersey, New Brunswick, New Jersey.
Department of Radiation Oncology, Memorial Sloan Kettering Cancer Center, New York, New York.
Int J Radiat Oncol Biol Phys. 2019 Jul 15;104(4):714-723. doi: 10.1016/j.ijrobp.2018.12.021. Epub 2018 Dec 14.
Prior authorization (PA) has been widely implemented for proton beam therapy (PBT). We sought to determine the association between PA determination and patient characteristics, practice guidelines, and potential treatment delays.
A single-institution retrospective analysis was performed of all patients considered for PBT between 2015 and 2018 at a National Cancer Institute-designated Comprehensive Cancer Center. Differences in treatment start times and denial rates over time were compared, and multivariable logistic regression was used to identify predictors of initial denial.
A total of 444 patients were considered for PBT, including 396 adult and 48 pediatric patients. The American Society for Radiation Oncology model policy supported PBT coverage for 77% of the cohort. Of adult patients requiring PA, 64% were initially denied and 32% remained denied after appeal. In patients considered for reirradiation or randomized phase 3 trial enrollment, initial denial rates were 57% and 64%, respectively. Insurance coverage was not related to diagnosis, reirradiation, trial enrollment, or the American Society for Radiation Oncology model policy guidelines, but it was related to insurance category on multivariable analysis (P < .001). Over a 3-year timespan, initial denial rates increased from 55% to 74% (P = .034). PA delayed treatment start by an average of 3 weeks (and up to 4 months) for those requiring appeal (P < .001) and resulted in 19% of denied patients abandoning radiation treatment altogether. Of pediatric patients, 9% were initially denied, all of whom were approved after appeal, and PA requirement did not delay treatment start (P = .47).
PA requirements in adults represent a significant burden in initiating PBT and cause significant delays in patient care. Insurance approval is arbitrary and has become more restrictive over time, discordant with national clinical practice guidelines. Payors and providers should seek to streamline coverage policies in alignment with established guidelines to ensure appropriate and timely patient care.
质子束治疗(PBT)已广泛实施了预先授权(PA)。我们旨在确定 PA 决策与患者特征、实践指南和潜在治疗延迟之间的关联。
对 2015 年至 2018 年间在一家美国国立癌症研究所指定的综合性癌症中心考虑接受 PBT 的所有患者进行了单机构回顾性分析。比较了随时间推移的治疗开始时间和拒绝率的差异,并使用多变量逻辑回归来确定初始拒绝的预测因素。
共有 444 名患者被考虑接受 PBT,包括 396 名成年患者和 48 名儿科患者。美国放射肿瘤学会(ASTRO)模型政策支持该队列中 77%的患者接受 PBT 覆盖。需要 PA 的成年患者中,64%的患者最初被拒绝,32%的患者在上诉后仍被拒绝。在考虑再放疗或随机 3 期试验入组的患者中,初始拒绝率分别为 57%和 64%。保险覆盖与诊断、再放疗、试验入组或 ASTRO 模型政策指南无关,但在多变量分析中与保险类别有关(P<0.001)。在 3 年的时间跨度内,初始拒绝率从 55%增加到 74%(P=0.034)。对于需要上诉的患者,PA 平均延迟治疗开始时间 3 周(最长可达 4 个月)(P<0.001),并导致 19%的拒绝患者完全放弃放疗。在儿科患者中,9%的患者最初被拒绝,所有患者在上诉后都获得了批准,并且 PA 要求没有延迟治疗开始(P=0.47)。
成人的 PA 要求代表了启动 PBT 的重大负担,并导致患者护理的重大延迟。保险批准是任意的,并且随着时间的推移变得更加严格,与国家临床实践指南不一致。支付方和提供者应寻求简化与既定指南一致的覆盖政策,以确保适当和及时的患者护理。