Department of Radiation Oncology, Washington University School of Medicine, St Louis, Missouri.
Department of Neurosurgery, Washington University School of Medicine, St Louis, Missouri.
Pract Radiat Oncol. 2020 Jul-Aug;10(4):e250-e254. doi: 10.1016/j.prro.2020.01.006. Epub 2020 Jan 28.
The medical necessity of stereotactic radiosurgery (SRS) is nonuniform across insurance policies. The American Society for Radiation Oncology (ASTRO) created a model policy based on the consensus of the radiation oncology community to communicate medically necessary indications for SRS. We compared the current insurance policies for SRS with those of the ASTRO model policy.
We identified 58 insurance payers and 3 national benefits managers with SRS policies. Among these, 7 insurance payers were excluded for policies that were not reviewed after 2015 and for not detailing individual medically necessary indications. For each of the indications listed in ASTRO's model policy, we determined the proportion of payers that considered SRS medically necessary. We compared these proportions for national versus regional payers and policies updated in the last 12 months versus those updated less often using Fisher exact and χ tests.
All insurance policies reviewed considered SRS as medically necessary for brain metastases, medically refractory trigeminal neuralgia, and arteriovenous malformations. Compared with national payers, regional payers were less likely to deem other schwannomas, and a boost for large cranial or spinal lesions medically necessary (P < .05). The indication with the lowest coverage was medically refractory movement disorders (44.4%), followed by medically refractory epilepsy (33.3%). However, policies that were updated within the last year were more likely to deem medical necessity for epilepsy, movement disorders, hemangioblastoma, pineal gland tumors, and other schwannomas.
Significant discrepancy remains among insurance policies for several indications in ASTRO's model policy for SRS; however, national payers and those with recent policy updates have a greater concordance with the ASTRO model policy.
立体定向放射外科（SRS）的医学必要性在不同的保险政策中并不统一。美国放射肿瘤学会（ASTRO）基于放射肿瘤学界的共识制定了一项模型政策，以传达 SRS 的医学必要性适应症。我们将当前的 SRS 保险政策与 ASTRO 模型政策进行了比较。
我们确定了 58 家保险支付者和 3 家具有 SRS 政策的国家福利管理者。其中，有 7 家保险公司因 2015 年后未进行审核或未详细说明个别医学上必要的适应症而被排除在外。对于 ASTRO 模型政策中列出的每一个适应症，我们确定了认为 SRS 具有医学必要性的支付者的比例。我们比较了全国性与区域性支付者以及最近 12 个月更新与更新频率较低的政策之间的这些比例，使用 Fisher 精确检验和 χ2 检验进行比较。
所有审查的保险政策都认为 SRS 对脑转移瘤、药物难治性三叉神经痛和动静脉畸形具有医学必要性。与全国性支付者相比，区域性支付者不太可能认为其他神经鞘瘤和大颅或脊柱病变的放疗具有医学必要性（P<0.05）。覆盖范围最低的适应症是药物难治性运动障碍（44.4%），其次是药物难治性癫痫（33.3%）。然而，在过去一年中更新的政策更有可能认为癫痫、运动障碍、血管母细胞瘤、松果体肿瘤和其他神经鞘瘤具有医学必要性。
ASTRO 的 SRS 模型政策中的几个适应症的保险政策仍存在显著差异；然而，全国性支付者和最近更新政策的支付者与 ASTRO 模型政策更为一致。
