Variations in Medical Necessity Determinations Across Commercial Insurance Carriers for Prostate Cancer Procedures.

Variation in commercial insurance coverage may lead to disparity in access to quality cancer care. We evaluated commercial insurance coverage determinations to assess the degree of variation across a national sample.

We identified the predominant carrier of commercial insurance in each state based on the 2020 U.S. Government Accounting Office (GAO-21-34) report on insurance. For each state, publicly available medical policies from 1/1/2021 to 1/31/2021 were analyzed for coverage of 3 widely accepted procedures: hydrogel spacer, fluciclovine PET, and intensity modulated radiation (IMRT) in low volume metastatic prostate cancer.

We analyzed 83 commercial medical policies across 51 States and District of Columbia. There was widespread variation in coverage policy. Hydrogel spacer was determined medically necessary in 9 states, mixed coverage in 8, not medically necessary in 22, and no available public policy in 12. Use of fluciclovine-PET required a minimum prostate specific antigen (PSA) level of 2 ng/mL in 9 states, 1 ng/mL in 17, any PSA in 7, mixed coverage in 12, and no publicly available policy in 6. IMRT in low volume metastatic prostate cancer was medically necessary in 17 states, not necessary in 7, and not stated in 27. Insurance carriers often used external utilization management (UM) companies such as AIM-Healthcare and Evicore Healthcare. These determinations were more restrictive than carriers which did not use UM.

Commercial medical policies vary widely in medical necessity determinations for novel prostate cancer treatment procedures that are FDA-approved and covered by Medicare. These data suggest a need for more consistent methodology for medical necessity determination to mitigate the current state where patients have unequal access to cancer procedures due to the location of residence and age.

International journal of radiation oncology, biology, physics. 2022 Jul 30 [Epub ahead of print]

Xinglei Shen, Daniel E Spratt, Stacie B Dusetzina, Ronald C Chen

Department of Radiation Oncology, University of Kansas Medical Center, Kansas City KS, USA. Electronic address: ., Department of Radiation Oncology, University Hospitals, Seidman Cancer Center, Case Comprehensive Cancer Center, Cleveland OH, USA., Department of Health Policy, Vanderbilt Medical Center, Nashville, TN, USA., Department of Radiation Oncology, University of Kansas Medical Center, Kansas City KS, USA.

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