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Gap between insurance policy language
and final decisions

Study finds majority of insurance denials overturned in pediatric proton patients

by Lauren Dubinsky , Senior Reporter
New research from Penn Medicine revealed that even though one in 10 pediatric cancer patients are initially denied coverage for proton therapy, nearly all ultimately receive approval.

“Because of the different way it moves within the body, proton radiotherapy can often spare normal tissues better than photon radiotherapy,” Dr. Eric Ojerholm, co-author of the study and radiation oncology instructor at Penn, told HCB News. “Cured pediatric patients are likely to live for a long time and be at risk for late toxicities from radiation, and pediatric developing normal tissues are more sensitive to effects from radiation than are adult tissues.”

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For the study, Ojerholm and his team evaluated five years' worth of insurance coverage data at Penn’s Roberts Proton Therapy Center, from 2010 to 2015. Out of the 287 cases, 89 percent were approved outright and 11 percent were initially denied.

After appeals were made, 97 percent of the denied cases were overturned and approved. However, a great deal of time and resources were wasted in that process.

The team uncovered that most of the denials were due to the age of the patient and the type of tumor they had. Some patients over age 18 develop a type of cancer that physicians deem pediatric because of how the tumor behaves.

Those cancers include neuroblastoma, rhabdomyosarcoma, germinoma and Ewing sarcoma. Physicians usually treat the cancer the same way they would treat a pediatric patient, but this patient population was initially denied four times as often as those 18 or younger.

In addition, cancers located outside the brain or spine were 4.5 times more likely to be denied. That may be due to the fact that the strongest evidence for pediatric proton therapy involves brain and spine tumors.

The appeal process took about a week on average and involved letters, peer-to-peer phone calls, or both in some cases. In 28 percent of the cases, multiple rounds of appeal were required before coverage was finally approved.

The team cautions that the study had limitations and that research will have to be conducted in other regions of the U.S. to confirm these results. A center in another part of the country would have its own mix of insurance carriers and plans, which could lead to different findings.

Penn also has an advisory board that assesses patients for proton therapy and only recommends those most likely to benefit from treatment. If another center skips that step, they may have more denials or fewer appeal reversals.

Ojerholm believes that there should be a way to streamline the approval process. He suggests changing the language of insurance policies to recognize the distinction of pediatric tumors, and classifying patients between ages 19 and 30 with pediatric cancers as pediatric cases.

“If the results are confirmed [in another study], then as a second step we could alert insurance companies to these data,” he said. “Ideally, this would prompt a discussion about ways to streamline the approval process for pediatric patients.”

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