Executive summary

Prior authorization remains a barrier to proton therapy access and is associated with frequent denials and treatment delays. This insurance coverage study is conducted with a statewide self-funded employer (n = 186,000 enrollees), incorporating a value-based analysis and ensuring preauthorization for appropriate indications. Coverage was ensured for prospective trials and five evidence-supported anatomic sites.

This study found that appropriate access to proton therapy does not necessitate overuse or significantly increase comprehensive medical costs. Objective evidence-based coverage polices ensure appropriate patient selection. Stakeholder collaboration can streamline patient access while reducing administrative burden.