Proton therapy room
Courtesy of Penn Medicine
Courtesy of Penn Medicine
ASTRO releases updated insurance coverage recommendations for proton therapy
July 13, 2017
by Lauren Dubinsky, Senior Reporter
In light of new research, the American Society for Radiation Oncology recently made updates to its insurance coverage guidelines for proton beam therapy.
"This policy update reflects the most current knowledge regarding which patients will benefit from — and therefore should have access to — this cutting-edge treatment," Dr. David C. Beyer, ASTRO Chair, said in a statement.
The original policy was issued in 2014 when the technology was still in its infancy. The updated Proton Beam Therapy Model Policy provides guidance on the clinical indications that are appropriate for treatment and should be covered by Medicare, Medicaid and private insurance.
The clinical indications are divided into two categories, based on evidence from published clinical data and current Medicare coverage. Coverage is recommended for Group 1, but it's only recommended for Group 2 if additional requirements are met.
For Group 1, five additions and one modification were made to the original guidelines:
For Group 2, coverage is recommended if the patient is enrolled in an Institutional Research Board-approved study or a multi-institutional registry that adheres to Medicare's Coverage with Evidence Development (CED) requirements.
However, evidence is accumulating for these indications that may push them into Group 1 in the future. Even though the policy states that no indications are considered inappropriate for CED, it does specify several systems for Group 2 indications:
Beyer said that ASTRO is committed to developing evidence to identify new areas where proton therapy may be beneficial as well as situations where it might not be.
ASTRO's Payer Relations Subcommittee developed the update guidelines, which were reviewed by the Health Policy Council and approved by the Board of Directors last month.
"This policy update reflects the most current knowledge regarding which patients will benefit from — and therefore should have access to — this cutting-edge treatment," Dr. David C. Beyer, ASTRO Chair, said in a statement.
The original policy was issued in 2014 when the technology was still in its infancy. The updated Proton Beam Therapy Model Policy provides guidance on the clinical indications that are appropriate for treatment and should be covered by Medicare, Medicaid and private insurance.
The clinical indications are divided into two categories, based on evidence from published clinical data and current Medicare coverage. Coverage is recommended for Group 1, but it's only recommended for Group 2 if additional requirements are met.
For Group 1, five additions and one modification were made to the original guidelines:
- Malignant and benign primary central nervous system tumors
- Advanced and/or unresectable head and neck cancers
- Cancers of the paranasal sinuses and other accessory sinuses
- Nonmetastatic retroperitoneal sarcomas
- Reirradiation cases where cumulative critical structure dose would exceed tolerance dose
- Hepatocellular cancer is no longer required to be treated in a hypofractionated regimen
For Group 2, coverage is recommended if the patient is enrolled in an Institutional Research Board-approved study or a multi-institutional registry that adheres to Medicare's Coverage with Evidence Development (CED) requirements.
However, evidence is accumulating for these indications that may push them into Group 1 in the future. Even though the policy states that no indications are considered inappropriate for CED, it does specify several systems for Group 2 indications:
- Non-T4 and resectable head and neck cancers (previously it was all head and neck malignancies)
- Nonmetastatic prostate cancer (previously it was grouped with genitourinary carcinomas)
Beyer said that ASTRO is committed to developing evidence to identify new areas where proton therapy may be beneficial as well as situations where it might not be.
ASTRO's Payer Relations Subcommittee developed the update guidelines, which were reviewed by the Health Policy Council and approved by the Board of Directors last month.