Andrew J Bishop1, J Andrew Livingston2, Matt S Ning3, Isaac D Valdez3, Cody A Wages3, Mary Fran McAleer3, Arnold C Paulino3, David R Grosshans3, Kristina D Woodhouse3, Randa Tao4, Michael E Roth5, G Brandon Gunn3, Susan L McGovern3. 1. Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas. Electronic address: abishop2@mdanderson.org. 2. Department of Sarcoma Medical Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas. 3. Department of Radiation Oncology, University of Texas MD Anderson Cancer Center, Houston, Texas. 4. Department of Radiation Oncology at the Huntsman Cancer Institute, University of Utah, Salt Lake City, Utah. 5. Department of Pediatrics, University of Texas MD Anderson Cancer Center, Houston, Texas.
Abstract
PURPOSE: Young patients, including pediatric, adolescent, and young adult (YA) patients, are most likely to benefit from the reduced integral dose of proton beam radiation therapy (PBT) resulting in fewer late toxicities and secondary malignancies. This study sought to examine insurance approval and appeal outcomes for PBT among YA patients compared with pediatric patients at a large-volume proton therapy center. METHODS AND MATERIALS: We performed a cross-sectional cohort study of 284 consecutive patients aged 0 to 39 years for whom PBT was recommended in 2018 through 2019. Pediatric patients were defined as aged 0 to 18 years and YA patients 19 to 39 years. Rates of approval, denials, and decision timelines were calculated. Tumor type and location were also evaluated as factors that may influence insurance decisions. RESULTS: A total of 207 patients (73%) were approved for PBT at initial request. YA patients (n = 68/143, 48%) were significantly less likely to receive initial approval compared with pediatric patients (n = 139/141; 99%) (P < .001). Even after 47% (n = 35 of 75) of the PBT denials for YA patients were overturned, YAs had a significantly lower final PBT approval (72% vs pediatric 99%; P < .001). The median wait time was also significantly longer for YA patients (median, 8 days; interquartile range [IQR] 3-17 vs median, 2 days; IQR, 0-6; P < .001). In those patients requiring an appeal, the median wait time was 16 days (IQR, 9-25). CONCLUSION: Given the decades of survivorship of YA patients, PBT is an important tool to reduce late toxicities and secondary malignancies. Compared with pediatric patients, YA patients are significantly less likely to receive insurance approval for PBT. Insurance denials and subsequent appeal requests result in significant delays for YA patients. Insurers need to re-examine their policies to include expedited decisions and appeals and removal of arbitrary age cutoffs so that YA patients can gain easier access to PBT. Furthermore, consensus guidelines encouraging greater PBT access for YA may be warranted from both medical societies and/or AYA experts.
PURPOSE: Young patients, including pediatric, adolescent, and young adult (YA) patients, are most likely to benefit from the reduced integral dose of proton beam radiation therapy (PBT) resulting in fewer late toxicities and secondary malignancies. This study sought to examine insurance approval and appeal outcomes for PBT among YA patients compared with pediatric patients at a large-volume proton therapy center. METHODS AND MATERIALS: We performed a cross-sectional cohort study of 284 consecutive patients aged 0 to 39 years for whom PBT was recommended in 2018 through 2019. Pediatric patients were defined as aged 0 to 18 years and YA patients 19 to 39 years. Rates of approval, denials, and decision timelines were calculated. Tumor type and location were also evaluated as factors that may influence insurance decisions. RESULTS: A total of 207 patients (73%) were approved for PBT at initial request. YA patients (n = 68/143, 48%) were significantly less likely to receive initial approval compared with pediatric patients (n = 139/141; 99%) (P < .001). Even after 47% (n = 35 of 75) of the PBT denials for YA patients were overturned, YAs had a significantly lower final PBT approval (72% vs pediatric 99%; P < .001). The median wait time was also significantly longer for YA patients (median, 8 days; interquartile range [IQR] 3-17 vs median, 2 days; IQR, 0-6; P < .001). In those patients requiring an appeal, the median wait time was 16 days (IQR, 9-25). CONCLUSION: Given the decades of survivorship of YA patients, PBT is an important tool to reduce late toxicities and secondary malignancies. Compared with pediatric patients, YA patients are significantly less likely to receive insurance approval for PBT. Insurance denials and subsequent appeal requests result in significant delays for YA patients. Insurers need to re-examine their policies to include expedited decisions and appeals and removal of arbitrary age cutoffs so that YA patients can gain easier access to PBT. Furthermore, consensus guidelines encouraging greater PBT access for YA may be warranted from both medical societies and/or AYA experts.
Authors: Theresa H M Keegan; Helen M Parsons; Yi Chen; Frances B Maguire; Cyllene R Morris; Arti Parikh-Patel; Kenneth W Kizer; Ted Wun Journal: J Natl Cancer Inst Date: 2019-11-01 Impact factor: 13.506
Authors: Lisa S Kahalley; Rachel Peterson; M Douglas Ris; Laura Janzen; M Fatih Okcu; David R Grosshans; Vijay Ramaswamy; Arnold C Paulino; David Hodgson; Anita Mahajan; Derek S Tsang; Normand Laperriere; William E Whitehead; Robert C Dauser; Michael D Taylor; Heather M Conklin; Murali Chintagumpala; Eric Bouffet; Donald Mabbott Journal: J Clin Oncol Date: 2019-11-27 Impact factor: 44.544
Authors: Safia K Ahmed; R Lor Randall; Steven G DuBois; William S Harmsen; Mark Krailo; Karen J Marcus; Katherine A Janeway; David S Geller; Joel I Sorger; Richard B Womer; Linda Granowetter; Holcombe E Grier; Richard G Gorlick; Nadia N I Laack Journal: Int J Radiat Oncol Biol Phys Date: 2017-08-24 Impact factor: 7.038