Top Line: We all know that insurance coverage tends to lag well behind development of new treatment techniques.
The Study: While we may consider many techniques used to treat prostate cancer relatively standard in clinical practice, that doesn’t mean insurance policies cover those techniques. This study evaluated 83 major commercial insurance policies across all states in the U.S. and the District of Columbia to determine whether they covered three relatively recently developed techniques: IMRT for low volume metastatic disease, rectal hydrogel spacer, and fluciclovine PET/CT. These were also selected because they are covered by Medicare and comply with NCCN Guidelines. IMRT for low volume metastatic disease wasn’t specifically addressed in policies covering 27 states, it was considered medically necessary in 17 states, and it was considered not necessary in 7 states. Rectal hydrogel spacer was considered not necessary in 22 states, necessary in just 9 states, mixed coverage in 8 states, and there was no specific policy in 12 states. Finally, for fluciclovine PET, there was coverage in all states, but this was mostly determined by PSA level. PSA had to be at least 2 in 9 states, at least 1 in 17 states, and there was no minimum PSA in 7 states. In the rest, there was mixed coverage or no specific policy. Importantly, coverage of these indicated techniques and procedures was most restrictive among insurance carriers that used utilization management companies such as AIM and Evicore.
TBL: A major factor limiting patients’ access to standard treatments and techniques for prostate cancer is the highly variable and inconsistent coverage by commercial insurance companies across the U.S. | Shen, Int J Radiat Oncol Biol Phys 2022