Insurance Coverage for Prostate MRIs Overly Restrictive

September 24, 2018

Coverage for prostate MRIs results in challenges for patients and referring physicians seeking to obtain ready access.

Private payers vary widely regarding provisions for prostate MRIs and are overly restrictive, according to a study published in the Journal of the American College of Radiology.

Researchers from the University of California in San Diego, UT Health San Antonio in Texas, and NYU Langone Health in New York city, investigated the national coverage landscape for prostate MRI services, assessing the presence of updated and accurate coverage requirements by private payers.

Using the database Policy Reporter, the researchers evaluated private payer coverage related to prostate MRI for 81 plans covering 149 million people in the United States. Both the indications and requirements for prostate MRI coverage were recorded in a variety of clinical scenarios, including initial diagnosis, staging, active surveillance, and suspected recurrence.

The results showed that overall, 11.1 percent of payers covered prostate MRI in biopsy-naïve patients with suspected prostate cancer; 88.9 percent required a prior negative biopsy. Nearly all payers also require either a rising prostate-specific antigen (PSA) or abnormal digital rectal examination (DRE). Rarely, a planned future MRI-targeted biopsy serves as a basis for MRI coverage.

Initial prostate cancer staging was covered by most payers, although typically with stringent indications, including  PSA of 20 ng/mL or higher, Gleason score of seven or eight or higher, stage T3 or T4, or 20 percent or higher risk of nodal metastases. Only 10 payers discuss active surveillance, however eight required a repeat biopsy before MRI.

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 address coverage after androgen deprivation treatment.

The researchers concluded that among private payers, prostate MRI coverage varied widely. The policies failed to recognize major clinical scenarios, were overly restrictive, and were often not reflective of current clinical practice, creating challenges for patients and referring physicians seeking to obtain ready access to prostate MRI services.