Insurance companies wind up covering proton therapy treatment for pediatric patients in 97% of cases they originally denied, according to a new study published online August 7 in Pediatric Blood & Cancer.
After analyzing five years of coverage decisions at the University of Pennsylvania (Penn) Roberts Proton Therapy Center, researchers discovered roughly 1 in 10 pediatric cancer patients are initially denied coverage. But once the decision is appealed, nearly all patients get approval, they found.
The researchers looked at five years of insurance coverage data for pediatric proton cases at the center. Of the 287 cases, 255 (89%) were approved outright, while 32 (11%) were initially denied. Following appeals, 31 of 32 initially denied cases (97%) were overturned and approved.
The two factors most associated with initial denial are age and tumor type. Some patients older than age 18 develop a cancer that doctors consider pediatric because of how the tumor typically behaves, such as with neuroblastoma, rhabdomyosarcoma, germinoma, and Ewing's sarcoma. Patients in this group were initially denied four times as often than those 18 or younger.
Cancers located outside the brain or spine were denied 4.5 times more frequently, likely because the strongest evidence for pediatric proton therapy is in brain and spine tumors, according to study co-author Eric Ojerholm, MD, an instructor in radiation oncology at Penn's Perelman School of Medicine. Insurers appear willing to accept these cases but may initially be more hesitant for other disease sites, according to the authors.
Despite the high rate of success on appeal, researchers note the process itself can be problematic: It takes about a week, involves letters, peer-to-peer phone calls, or both in some cases. In 28% of cases, it took multiple rounds of appeal before coverage was finally approved.
To streamline the process, the researchers suggest changing insurance policy language to recognize the distinction of pediatric tumors. They also propose classifying patients between the ages of 19 and 30 who have these pediatric cancers as pediatric cases, which would eliminate one of the common causes of denial.
Limitations of the study included the single data source -- a different center in a different part of the country would have its own unique mix of insurance carriers and plans, which may produce a different result, according to the authors. Also, Penn has an advisory board that evaluates patients for proton therapy and only recommends those most likely to benefit from the treatment. If other centers skip that step, they may see more denials or fewer reversals on appeal, they noted.
