3607 - Independent Review Organization and Proton Therapy: Multi-State Analysis and Legal Procedural Strategies

E. Augustin¹, E. D. Brooks², T. T. W. Sio³, M. S. Ning⁴, N. P. Mendenhall¹, and M. B. Palmer⁵; ¹Department of Radiation Oncology, University of Florida College of Medicine, Jacksonville, FL, ²Department of Radiation Oncology, University of Florida College of Medicine, Gainesville, FL, ³Department of Radiation Oncology, Mayo Clinic, Phoenix, AZ, ⁴Department of Radiation Oncology, MD Anderson Cancer Center, Houston, TX, ⁵Legion Healthcare Partners, LLC, Houston, TX

Purpose/Objective(s): Insurance authorization for proton therapy continues to be a challenge for many proton centers. Understanding current denial trends can further prepare institutions for success in enhancing patient access. In particular, leveraging independent review organizations (IROs) use for denials is underutilized. IRO is an accredited third-party organization charged with reviewing proton cases when payors deny care offering an unbiased form of review. Reasons for IRO underutilization may stem from the lack of awareness or unfamiliarity. Herein, we discuss how IRO is in effective instrument for securing access to necessary care that proton centers may not be familiar. Materials/

Methods: We analyzed the IROs of three geographically distinct states (Florida, Texas, and Arizona) by using publicly available data through each state’s Department of Insurance. We discuss IRO approval trends, strategies, and legal procedures. We used the data to interpret how IRO approvals and denials have changed, how decisions are made, and offer recommendations based on these insights.
Results: Our three-state aggregate analysis spanned from 2011 - 2021 revealing a crude 25.3% average total IRO approval rate for proton therapy. Two states showed the average rate of overturn increased year after year from 0% - 12.5% at the start of data collection to 8.3% 37.5% at last date of data availability. This translated into a +1.6% - 6.1% rate of increase in IRO approval of proton therapy year after year (P=0.06). When evaluating IRO approval rate by histology, sarcomas and esophagus cancer had the highest levels of approval rate (50% - 83.3%) followed by breast cancer (33.9%) and head and neck cancer (31.4%). Disease histologies with the lowest IRO approval overturn rates were rectal/anal cancer (11.1%), liver/pancreas cancer (11.1%), and prostate cancer (3.8%). IRO led to an increase of access of care to proton therapy from 1 in 5 patients to 1 in 3 patients. Qualitative data showed that reference to guideline support for proton therapy, published studies, trial inclusion, and highly personalized letters were all associated with case approvals. On multi-person IRO panels, some reviewers used the same data and facts to arrive at completely opposing conclusions making the IRO process somewhat arbitrary and prone to subjective interpretation highlighting. Thus, indicating the need for health utilization management reform and optimization of each patient’s IRO submission.
Conclusion: IRO can offer an objective remedy to insurance plans with historic proton unfavorable policies or denials indicating an increase for patients to gain access to proton therapy. There is a need for health utilization management reform and optimization for each patient’s IRO submission. Proton centers should utilize IRO to increase appropriate patient access allowing these patients to receive the crucial care need for treating their cancers.