Prostate magnetic resonance imaging (MRI) has becoming increasingly important in diagnosing and managing prostate cancer (PCa), but private payer coverage of prostate MRI varies widely and frequently does not reflect current clinical practice, investigators found. Coverage policies fail to recognize major clinical scenarios and is overly restrictive.
“This creates challenges for patients and referring physicians seeking to obtain ready access to prostate MRI services,” Michael T. Booker, MD, MBA, of the University of California, San Diego, and colleagues concluded in a paper published online ahead of print in the Journal of the American College of Radiology.
Dr Booker's team used the Policy Reporter database to evaluate private payer coverage related to prostate MRI for 81 plans covering 149 million people in the United States. Overall, 11% of payers cover prostate MRI in biopsy-naïve patients with suspected prostate cancer (PCa), with the remaining 88.9% requiring a prior negative biopsy. Nearly all payers require either a rising PSA or abnormal rectal examination. “Rarely, a planned future MRI-targeted biopsy serves as a basis for MRI coverage,” they wrote.
Most payers cover initial staging, although typically with stringent indications, such as a PSA level of 20 ng/mL or higher, Gleason score of 7 or 8, stage T3 or T4 and a 20% or greater risk of nodal metastases.
The authors noted that prostate MRI has been included in various recent PCa position statements issued by professional organizations. For example, an American Urological Association (AUA)-Society of Abdominal Radiology collaborative statement supports prostate MRI following a negative prostate biopsy, and an AUA policy statement supports a role for prostate MRI in some biopsy-naïve patients.
“Despite the growth of prostate MRI, it is unclear if insurance coverage has kept pace with evolving clinical practice,” Dr Booker's team wrote. “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.”