Variations in Proton Therapy Coverage in the State of Texas: Defining Medical Necessity for a Safe and Effective Treatment.

Purpose: The definition of medical necessity and indications for coverage of proton beam therapy (PBT) for the treatment of cancer can vary greatly among different professional societies (PSs) and payors. Variations in policies introduce substantial inefficiencies and limit access for patients who may clinically benefit from PBT. The purpose of this study was to analyze differences in medical necessity and coverage policies among payors and a PS.

Materials And Methods: Peer-reviewed references and coverage decisions were abstracted from the coverage policies of each of the major payors in the state of Texas (Aetna-TX, UnitedHealthcare-TX, Blue Cross Blue Shield-TX) as well as from a representative PS, the Particle Therapy Cooperative Group. Differences in number and quality of references as well as coverage decisions were analyzed with descriptive statistics.

Results: Proton beam therapy coverage in the state of Texas varied among payors and the PS for several disease sites, including the central nervous system, eyes, and prostate. The PS cited more references and higher levels of evidence than payor policies ( < .01). Levels of evidence were inconsistent between policies. Interestingly, only 18% to 29% of cited references overlapped between policies.

Conclusions: Payors and PSs have independent and nonstandardized processes for determining PBT coverage, which result in variations in both coverage and evidence cited. These differences can lead to clinical inefficiencies and may reduce access to PBT based on payor status rather than clinical utility. A collaborative approach among all stakeholders would help create a more consistent, equitable, and patient-centered PBT policy that could identify areas for further evidence development.