Varying prostate MRI insurance coverage poses problems for patients, providers

According to new research in the Journal of the American College of Radiology, prostate MRI has various problems—including varying insurance coverage, a failure to recognize major clinical scenarios and a restrictive, inflexible clinical practices.

To compound the problem, CMS has not issued National Coverage Determinations for prostate MRI, and it has not provided guidance on its medical necessity.

The varied coverage and lacking guidance have created challenges for patients and referring physicians who seek to obtain immediate access to prostate MRI services.

“Despite the growth of prostate MRI, it is unclear if insurance coverage has kept pace with evolving clinical practice,” wrote lead author Michael T. Booker, MD, MBA, of the University of California, San Diego, and colleagues. “This is largely because the payer landscape is highly variable, with multiple private payers, radiology benefit managers, and associated government policies all creating unique requirements.”

Booker and colleagues sought to examine national coverage of prostate MRI services. They assessed private payer coverage related to prostate MRI for 81 plans covering 149 million individuals in the U.S. Indications and requirements for prostate MRI coverage were recorded in various clinical scenarios—including initial diagnosis, staging, active surveillance and suspected recurrence.

“We observed that 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,” the authors wrote. “Moreover, payers are often not comprehensive in their approach to dealing with clinically relevant scenarios and indications such as active surveillance and MRI-ultrasound fusion-targeted biopsy.”

Overall, only 11 percent of private payers covered prostate MRI in patients who never had a biopsy but were suspected to have prostate cancer. The other 89 percent of payers required a private negative biopsy—and of these payers, 71 payers also required a rising prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE).

They found a planned future MRI-targeted biopsy would rarely serve as basis for coverage. The researchers noted about 86 percent of payers cover prostate MRI for initial staging after meeting certain indications including a PSA reading of less than 20 mg/mL, a Gleason score of 7, 8 or less, stage T3 or T4, or less than a 20 percent risk of nodal metastases.

Only 10 payers discussed prostate MRI coverage in the active surveillance setting. All but two of the payers required a repeat prostate biopsy before imaging can be performed. Coverage for detection of post-treatment recurrence often required a rising PSA or abnormal DRE, and occasionally only if a CT is first performed. Only 10 of 81 payers addressed coverage after androgen deprivation treatment.

The researchers noted their study did not assess regional variations, saying it is imperative for radiology groups to understand the particularities of their regional payer mix and continue to work locally to help update guidelines in their region.

“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.