Insurance Approval for Proton Therapy in Patients With Thoracic Malignancies: An Experience From a Cost-Neutral Payor Environment.

Purpose/Objective(s) Despite the significant potential benefits, insurance approval for proton therapy to treat thoracic malignancies can be challenging, often requiring multiple layers of appeals process that adds significant burden of care while also delaying treatments. To increase insurance buy-in, at our institution we use an alternate payment model of cost-neutrality that charges intensity modulated proton therapy (IMPT) at the same rate as the standard of care photon-based IMRT/VMAT in a hospital setting. In this analysis, we seek to review success rates in obtaining insurance approval for IMPT when treating thoracic malignancies in our cost-neutral payor environment. Materials/Methods We performed a retrospective analysis of insurance approval records of patients with thoracic (lung, esophageal, thymic, mesothelial) malignancies for whom IMPT was recommended between years 2016-2020. Descriptive analyses were performed to obtain rates of insurance approvals and denials along with success rates of peer-to-peer (P2P) and appeals processes. Results In the study period, insurance approval data for 435 patients with thoracic malignancies who were offered IMPT was tracked. Tumor types for these patients were lung (263), esophageal (105), mesothelioma (37) and thymic (30) malignancies. The initial insurance approval rate without needing additional review was 80.9%. Of these, 222 (63.1%) patients had Medicare/Medicaid primary. For eight patients, an initial determination was not feasible since there was no mechanism for review with health plan. Among the 75 patients with initial denial, a P2P option was available only for 42 (56%) patients with successful reversal of denial in 28.5%. Of the remaining 30 patients with P2P denial, 1st level of appeal overturned the denial in 8 (27%) patients with two more patients getting approved after additional levels of appeals. In the 33 patients where a P2P option was not available, treatment was approved in 6 (18%) patients at 1st level of appeal. Due to clinical needs, six patients were approved by our financial team without a final determination assuming risk of denial. Option to submit a proton versus photon comparison treatment plan was available only in 16 of the 75 denied patients, of whom approval was granted in only 3 patients. Overall, the final approval was obtained in 386 (88.7%) patients. By disease site, final approval rate was 90.5% for esophageal, 89.3% for lung, 89.2% for mesothelial and 76.7% for thymic origin malignancies. Conclusion In this largest reported experience from a cost-neutral payor environment that charges IMPT at the hospital-rate of IMRT/VMAT, we note nearly 90% insurance approval rates for thoracic cancers with 80% of all patients avoiding the need for burdensome P2P and appeal processes. P2P option was available in only half of the patients with a success rate of less than 30%. Our analysis encourages institutions to explore the cost-neutral environment while urging payors to provide efficient and fair P2P and appeals process.