Department of Radiation Oncology, Allegheny General Hospital, Pittsburgh, Pennsylvania.
Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas.
Pract Radiat Oncol. 2020 Sep-Oct;10(5):324-329. doi: 10.1016/j.prro.2019.08.005. Epub 2019 Aug 22.
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).
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.
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).
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.
本研究旨在比较美国放射肿瘤学会（ASTRO）的强度调制放射治疗（IMRT）、立体定向放射外科（SRS）、立体定向消融放射治疗（SABR）和质子束治疗（PBT）的模型政策（MPs）与美国 5 家最大的公开商业保险公司的覆盖政策（即 Aetna、Anthem、Cigna、Humana 和 United Healthcare）。
从 ASTRO 最新发布的 MPs 和 5 家保险公司的 2019 年版（最新）发布的覆盖政策中提取了适用于疾病部位（及其特定临床环境）的 IMRT、SRS、SABR 和 PBT 的适当适应证。制表后，计算每种方式下 ASTRO MPs 和保险政策之间的一致性。
所有 5 家保险公司的政策都支持中枢神经系统、头颈部、肝胆胰、肛门和前列腺癌的肿瘤的 IMRT。腹膜后肿瘤（n=0 家保险公司）和膀胱癌（n=1 家保险公司）的覆盖范围最小。对于 SRS，所有保险公司都涵盖良性脑肿瘤、脑转移瘤、动静脉畸形和三叉神经痛。没有一家保险公司为治疗抵抗性癫痫提供 SRS。对于 SABR，原发性肝癌、肺癌和低危/中危前列腺癌都得到了所有保险公司的覆盖，而没有一家保险公司允许 SABR 治疗原发性肝胆肿瘤。只有一家保险公司为原发性/转移性肾上腺疾病和原发性肾癌提供 SABR。所有保险公司都批准 PBT 用于眼部黑色素瘤、颅底肿瘤和儿科恶性肿瘤。ASTRO MPs 列出了 4 种 PBT 情况（即脊柱疾病、腹膜后肉瘤、头颈部肿瘤和具有遗传辐射敏感性综合征的患者），但没有一家保险公司涵盖。保险公司与 ASTRO MPs 之间的一致性为 IMRT 为 67.8%，SRS 为 72.0%，SABR 为 58.4%，PBT 为 41.8%（P=0.005）。
IMRT、SRS、SABR 和 PBT 的覆盖指南因 5 家主要保险公司而异，与 ASTRO 覆盖指南相比可能存在很大差异。ASTRO 成员、支付者和政策制定者之间仍有几个具体领域需要进行持续和未来的对话。
