Alliance for Proton Therapy Access Letter to Insurers
I am writing on behalf of the Alliance for Proton Therapy Access, a coalition of cancer care advocates working to ensure cancer patients in need of proton therapy receive fair and timely access to treatment.
The Alliance for Proton Therapy Access seeks to educate insurers, policymakers, employers, and the public about the critical value proton therapy adds to cancer patients’ treatment options. We strive to ensure that cancer patients have access to timely, consistent and fair payment decisions by health plans when their physician has recommended proton therapy as one of their best treatment options.
To that end, this letter is intended to open a dialogue with you in order to better understand your health plan’s process and policies for determining coverage of proton therapy for your customers diagnosed with cancer. Ideally, we would like to meet with you and your clinical policy team to better understand your processes in making proton therapy coverage decisions for cancer patients seeking proton therapy treatment.
We know that cancer patients, radiation oncologists, and proton centers have varying experiences when seeking insurance coverage for proton therapy for a variety of cancer diagnoses. Patients with certain diagnoses are approved immediately by some health plans, whereas patients with atypical diagnoses must go through multiple denials, appeals and eventually independent review to try to achieve coverage. Health plans throughout the country are inconsistent in their coverage of proton therapy, which results in wide variation of patient access depending on the patient’s location and health plan. When choosing their insurance, people do not review coverage policies for all diagnoses that they could possibly have in their future. Rather, they rely upon an understanding that their insurer will provide coverage for the safest and most effective treatments when they need it the most.
Despite FDA clearance, clinical evidence and expert recommendations from radiation oncologists, and recommendations by multi-physician tumor boards, many cancer patients experience long waiting periods from their health plans for final proton therapy coverage decisions. Time is precious for many of these patients, whose treatment cannot wait the weeks or months it may take for internal and external appeals. Additionally, many patients seeking proton therapy have unique situations or disease types that may never be the subject of the clinical research studies, and for them the approval process can be daunting.
The Alliance is launching a campaign to ensure that all cancer patients are given a fair and timely opportunity to receive the cancer treatment their physicians feel will offer them the best chance for survival and high quality of life during and after treatment.
As part of this campaign, we are surveying insurers to clarify their policies and procedures as they relate to proton therapy. By finding out more about your policies and processes, and through productive dialogue, we hope to find positive solutions that will help patients and their oncologists effectively navigate the coverage determination process in a timely manner.
We are interested in hearing from you about the processes and policies [Insurer] follows when your members diagnosed with cancer request coverage for proton therapy. Specifically, we are requesting a response to the following questions:
- Peer to Peer Process
- Does [Insurer] offer the opportunity for a peer-to-peer discussion with the patient’s radiation oncologist regarding the merits of the patient request for proton therapy prior to issuing a denial for coverage? If no, then why not?
- Does [Insurer] offer a peer-to-peer discussion with a radiation oncologist within your company who has previous experience using proton therapy to treat cancer patients? What is the process by which a member can request a review by a physician who has actually utilized proton therapy as a treatment modality?
- Does your company’s physician reviewer have the authority to approve a case that was initially denied? If so, how often do physician reviewers overturn initial denial decisions through the peer-to-peer process? (Please be specific with percentage.)
- How do your company’s peer reviewers handle situations in which the patient’s additional clinical conditions should be considered outside of the coverage policy?
- How often do your physician reviewers consider the cost of treatment in their decision for coverage of proton therapy? How are physicians informed of the various costs of treatment options available to a patient?
- Proton Therapy Coverage Policy and Process
- Does [Insurer] apply the same medical coverage policies for all insurance products it offers (i.e. Medicaid, Medicare, exchange, and commercial)?
- Do you use the exact same proton therapy medical coverage policy for both your self-funded and fully insured insurance products? How do you handle a situation in which a self-funded client would like to expand their coverage beyond the health plan’s standard medical policy for a certain member or overall for their plan?
- What is the process that [Insurer] utilizes when a patient’s diagnosis or clinical condition is uncommon enough that a randomized controlled trial or peer reviewed study on proton therapy is unavailable or is likely never to be performed?
- Does [Insurer] have an expedited appeal process that allows a request for proton therapy to go directly from initial denial to a third party independent review organization (IRO) when a patient has limited time to make a treatment decision? Explain how a patient would request an expedited independent review of a denial for coverage and how long that process would take. (Please be specific.)
- Does your proton therapy coverage policy factor in the cost of the care when determining whether or not to cover treatment for a patient? How is that cost of care determined when comparing proton therapy treatment to other approved treatment modalities?
We look forward to engaging in an ongoing dialogue with [Insurer] to develop a clear understanding of policies and procedures you have in place for coverage of proton therapy to treat cancer.
During the course of our campaign, we will be sharing the information we gather with patient advocates and the media to increase awareness about the value of proton therapy and the importance of a timely, transparent and fair process for coverage decisions by insurers.
We respectfully request a written response to the questions posed above within 45 days so we can provide a timely update to the patients and caregivers whom we represent. We would also welcome the opportunity to have an open dialogue with you, either in-person or by phone. We would include one or more physicians from our Scientific Advisory Committee and a patient from our Board in this discussion. Ultimately, we hope to find ways to improve the [Insurer] members’ experience and access to timely and reasonable coverage decisions for proton therapy when faced with different treatment options for their cancer.
Thank you in advance for your time and attention to this urgent patient care matter.
Alliance for Proton Therapy Access