Commercial Insurance Coverage of Advanced Radiotherapy Techniques Compared to American Society for Radiation Oncology Model Policies.

To compare and contrast the American Society for Radiation Oncology (ASTRO) Model Policies (MPs) for intensity-modulated radiation therapy (IMRT), stereotactic radiosurgery (SRS), stereotactic ablative radiotherapy (SABR), and proton beam therapy (PBT) with the coverage policies constructed by five of the largest publicly-available commercial insurers throughout the United States (Aetna, Anthem, Cigna, Humana, United).Appropriate indications for IMRT, SRS, SABR, and PBT by disease site (and particular clinical setting thereof) were extracted from the most recently published ASTRO MPs and published coverage policies (2019 editions) of the five carriers. Following tabulation, concordance between ASTRO MPs and insurance policies were calculated for each modality.All five insurer policies supported IMRT for neoplasms of the central nervous system, head/neck, hepatopancreaticobiliary region, along with anal and prostate cancers; the least covered were retroperitoneal tumors (n=0 carriers) and bladder cancer (n=1). For SRS, all carriers covered benign brain tumors, brain metastases, arteriovenous malformations, and trigeminal neuralgia; none covered SRS for medically refractory epilepsy. For SABR, primary liver, lung, and low-/intermediate-risk prostate cancer were covered by all insurers; none allowed SABR for primary biliary neoplasms, and only one each covered SABR for primary/metastatic adrenal disease and primary renal cancer. All carriers approved PBT for ocular melanoma, skull base tumors, and pediatric malignancies. The ASTRO MP listed four PBT scenarios (spinal disease, retroperitoneal sarcoma, head/neck neoplasms, and patients with genetic radiosensitivity syndromes) not covered by any insurer. Concordance between insurance carriers and ASTRO MPs were 67.8% for IMRT, 72.0% for SRS, 58.4% for SABR, and 41.8% for PBT (p=0.005).Coverage guidelines for IMRT, SRS, SABR, and PBT vary across 5 major insurance providers and may be substantially discordant when compared to ASTRO coverage guidelines. There remain several specific areas where ongoing and future dialogue between ASTRO, payers, and policymakers remains essential.