National private-payer prostate MRI coverage restrictive, varied

MRI has become a central part of diagnosing and managing prostate cancer, but private payer coverage has not kept up with this technological trend, reported authors of a recent Journal of the American College of Radiology study.

“Prostate MRI coverage is not only highly variable, but also quite restrictive and not necessarily in accordance with current clinical practice, which can create problems for patients and physicians,” wrote Michael T. Booker, MD, with the University of California, San Diego, and colleagues.

Researchers used the Policy Reporter online database to analyze prostate MRI private payer coverage of 81 health plans utilized by 149 million people in the U.S.

Coverage was broken down into five categories by clinical scenario: suspected prostate cancer in biopsy- naïve patients, suspected cancer with prior negative biopsy, initial staging with prior positive biopsy, active surveillance with prior positive biopsy and suspected recurrence following treatment.

Biopsy-naïve coverage

Results showed slightly more than 11 percent of payers covered prostate MRI in biopsy-naïve patients with suspected cancer—nearly 89 percent required a prior negative biopsy for coverage.

Prostate-specific antigen (PSA) remains a popular screening technique, but its high downstream costs should position prostate MRI as a viable, cost-effective alternative, the authors argued.

Initial prostate cancer staging coverage

Initial staging was covered by most, but usually with highly inflexible marks, such as a PSA level greater than or equal to 20 ng/mL and results greater than or equal to a 20 percent risk of nodal metastases.

These requirements are often not concordant with American Urological Association guidelines and disregard the role of prostate MRI in guiding therapy plans and aiding personalized treatment decisions, Booker and colleagues wrote.

Active surveillance coverage

Of the 81 payers analyzed in this study, two cover prostate MRI in active surveillance populations without a repeat biopsy.

According to Booker and colleagues, this also conflicts with current guidelines which promote prostate MRI’s ability to evaluate the disease progression noninvasively.

Additionally, the team noted, “prostate MRI has also been shown to be cost-effective in evaluating patients on active surveillance, both by improved detection rate of high-grade cancer and in potentially precluding biopsy and subsequent complications.”

Recurrence coverage

Results showed coverage in this area often requires a rising PSA or abnormal digital rectal examination result. Ten of the 81 payers analyzed address coverage after androgen deprivation treatment, leaving room for “ambiguity and misclassification,” Booker et al. wrote.

Going forward, the authors suggested radiology groups seek to understand variations in their regional coverage and work toward updating local guidelines to improve care.

“Regardless of the path forward, it will be important for radiologists, urologist, patients, and their stakeholders to continue to advocate for coverage of prostate MRI given its clinical efficacy and added value to patient care,” Booker et al. concluded.