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Variations in Medical Necessity Determinations Across Commercial Insurance Carriers for Prostate Cancer Procedures by Xinglei Shen; Daniel E. Spratt; Stacie B. Dusetzina; Ronald C. Chen is a Medicine article available to read on EtoBox.

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## Purpose: Variation in commercial insurance coverage may lead to disparity in access to quality cancer care. we evaluated commercial insurance coverage determinations to assess the degree of variation across a national sample. ## Methods and materials: We identified the predominant carrier of commercial insurance in each state based on the 2020 us government accounting office (gao-21-34) report on insurance. for each state, publicly available medical policies from january 1, 2021 to january 31, 2021 were analyzed for coverage of 3 widely accepted procedures: hydrogel spacer, fluciclovine- positron emission tomography (pet), and intensity modulated radiation in low volume metastatic prostate cancer. ## Results: We analyzed 83 commercial medical policies across 51 states and district of columbia. there was widespread variation in coverage policy. hydrogel spacer was determined medically necessary in 9 states, mixed coverage in 8, not medically necessary in 22, and no available public policy in 12. use of fluciclovine-pet required a minimum prostate specific antigen level of 2 ng/ml in 9 states, 1 ng/ml in 17, any minimum prostate specific antigen in 7, mixed coverage in 12, and no

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Author

Xinglei Shen; Daniel E. Spratt; Stacie B. Dusetzina; Ronald C. Chen

Publisher

Elsevier BV

Published

2023

Language

EN

Field

Medicine (Health Sciences)