Brooks Eric D, Sio Terence T, Ning Matthew S, Morris Christopher G, Mendenhall Nancy P, Turner Montreal, Vergara Noreen K, Palmer Matthew, Artz Mark E
Premier Radiation Oncology Associates, Clearwater, Florida, USA.
Department of Radiation Oncology, Mayo Clinic, Phoenix, Arizona, USA.
Int J Part Ther. 2025 Feb 17;15:100741. doi: 10.1016/j.ijpt.2025.100741. eCollection 2025 Mar.
Securing insurance authorization for proton therapy remains a challenge for many centers. When health insurance or employer-sponsored health plans deny coverage, Independent Review Organizations (IROs) can review proton therapy cases. However, despite providing an independent review pathway, IROs are often underutilized in securing approvals for care following a denial.
We analyzed trends in IRO approvals, strategies, and legal procedures using publicly available data from California (CA), Washington (WA), and New York (NY).
The aggregate analysis of the 3 states revealed an IRO average approval rate for proton therapy of 42.1%, with varying trends across states. All 3 states showed increases in IRO approval rates over time, averaging annual increases of +5.0%, +2.3%, and +7.2% for CA, WA, and NY, respectively. Sarcoma showed the highest IRO approval rate at 84.6%, followed by GYN cancers at 55.6% and breast cancer at 51.4%. CNS tumors and lymphomas had moderate approval rates at 44.7% and 40.0% respectively. Head and neck cancers had a 33.3% approval rate, while thoracic malignancies were at 36.8%. The lowest IRO approval rate was seen in prostate cancer at 16.5%. Qualitative analysis revealed that referencing guidelines, discussing published studies, citing trial inclusion, and submitting personalized letters were associated with higher IRO approval rates.
IRO reviews provide a more objective remedy for patients denied care through internal appeals, particularly for plans with historically unfavorable proton policies. Our study demonstrates that IRO appeals provide a valuable pathway to proton therapy access with higher overturn rates improving significantly in recent years. Nearly half of initially denied patients eventually received approval through this process. Proton centers should strategically utilize IRO reviews to increase patient access and improve approval chances.
为质子治疗获得保险授权对许多中心来说仍是一项挑战。当健康保险或雇主赞助的健康计划拒绝承保时，独立审查组织（IRO）可以审查质子治疗病例。然而，尽管提供了独立审查途径，但IRO在确保拒绝后护理批准方面往往未得到充分利用。
我们使用来自加利福尼亚州（CA）、华盛顿州（WA）和纽约州（NY）的公开数据，分析了IRO批准趋势、策略和法律程序。
对这三个州的综合分析显示，IRO对质子治疗的平均批准率为42.1%，各州趋势不同。所有三个州的IRO批准率都随时间增加，CA、WA和NY的年平均增长率分别为+5.0%、+2.3%和+7.2%。肉瘤的IRO批准率最高，为84.6%，其次是妇科癌症，为55.6%，乳腺癌为51.4%。中枢神经系统肿瘤和淋巴瘤的批准率中等，分别为44.7%和40.0%。头颈癌的批准率为33.3%，而胸部恶性肿瘤为36.8%。IRO批准率最低的是前列腺癌，为16.5%。定性分析表明，参考指南、讨论已发表的研究、引用试验纳入标准以及提交个性化信件与较高的IRO批准率相关。
IRO审查为通过内部申诉被拒绝治疗的患者提供了更客观的补救措施，特别是对于那些历史上质子政策不利的计划。我们的研究表明，IRO申诉为质子治疗提供了一条有价值的途径，近年来推翻率显著提高。近一半最初被拒绝的患者最终通过这一过程获得了批准。质子中心应战略性地利用IRO审查，以增加患者获得治疗的机会并提高批准几率。
