Insurance Coverage for Adjuvant Proton Therapy in the Definitive Treatment of Breast Cancer.

PURPOSE: To determine factors that influence insurance approval for breast cancer patients for whom adjuvant proton therapy (PT) is recommended. PATIENTS AND METHODS: We sought to identify factors associated with PT approval among 131 insured patients seen in consultation between 2014 and 2018 and recommended adjuvant PT. Insurance status included: commercial, 76 patients (58%); Medicare, 41 (31%); and Medicaid, 14 (11%). Ninety-six patients (73%) had policies that "covered" PT. Insurance "coverage" for PT was not associated with final approval nor was lack of "coverage" associated with denial despite additional steps of medical review, peer-to-peer discussion, patient appeal, and judicial review.In seeking approval, the following steps were required: medical review, 73 patients (56%); comparative dosimetry, 34 patients (26%); peer-to-peer discussion, 20 patients (15%); and administrative law judge, 1 patient (1%). A multivariate analysis of predictors for final insurance approval was conducted including the following covariates: T stage (Tis-T2 vs T3-T4); N stage (N0 vs N1-N3); laterality (left or bilateral vs right); insurance type (commercial vs Medicare/Medicaid) combined with potential insurance coverage (covered vs not covered); time period (2014-2016 vs 2017-2018); and age (<57 years vs 57 and older).
RESULTS: Insurance approval was obtained for 93/96 patients (97%) with insurance that covered PT versus 23/35 patients (66%) whose insurance did not cover PT. Insurance approval stratified by insurance type and coverage was: commercial-covered, 52/52 patients (100%); Medicare or Medicaid-covered, 41/44 (93%); commercial-not covered, 16/22 (73%); and Medicare or Medicaid-not covered, 7/13 (54%).On multivariate analysis, factors impacting approval revealed T stage, p=0.3127; N stage, p=0.8524; laterality, p=0.1829; insurance type combined with potential coverage, p<0.0001; time period, p=0.2731; and age, p=0.6678.
CONCLUSION: The only parameter that significantly influenced approval for treatment with PT was insurance type combined with potential coverage with ultimate approval rates ranging from 54% to 100%. © Copyright 2019 The Author(s).