Two radiation oncologists, Eric Ojerholm, MD and Christine Hill-Kayser, MD, at the Roberts Proton Therapy Center of the University of Pennsylvania in Philadelphia, have identified an issue with insurance company reimbursement for Proton Therapy claims. In a study of 287 cases, all of which were classified as pediatric primary tumors, roughly 11% of claims that were initially denied for insurance reimbursement were later approved upon appeal. According to Dr. Ojerholm, and Dr. Hill-Kayser, this process is stressful and inefficient.
In their case study of 287 primary pediatric tumors from 2010 to 2015, the appeals process for an initially denied insurance claim for proton beam therapy (PBT) took an average of 7.5 days, and included a combination of letters and telephone calls. In pediatric cases especially, time is always of the essence in treatment options. Therefore, this delay in coverage is placing unnecessary stress on families who are already in crisis. Of the cases submitted for reimbursement, 59% were primary Central Nervous System (CNS) tumors, 29% were non-CNS tumors, and 12% were non-CNS lymphomas. 88% of the patients were younger than 18-years-old, and 12% were ages 19 to 30.
The primary reason for the denials by the insurance companies is a lack of proven efficacy of proton therapy. For this reason, some physicians and researchers have been found to side with the insurance companies regarding approvals for this particular treatment, claiming that it has always been highly controversial. To date, only one study, on lung cancer, has final efficacy results, and proton therapy was not found to be more effective than the current, standard protocol. Therefore, insurance denials have continued, with no movement by the insurance companies towards creating a more streamlined process for filing these claims.
At the end of Dr. Ojerholm and Dr. Hill-Kayser’s study, 286 of the 287 were approved for proton therapy.
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