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J Am Coll Radiol. 2019 Jan;16(1):24-29. doi: 10.1016/j.jacr.2018.07.009. Epub 2018 Sep 11.

National Private Payer Coverage of Prostate MRI.

Author information

1
Radiology, University of California, San Diego, California. Electronic address: booker.michael@gmail.com.
2
South Texas Radiology Group, San Antonio, Texas; UT Health San Antonio, San Antonio, Texas.
3
Department of Radiology, NYU Langone Health, New York, New York.

Abstract

PURPOSE:

To investigate the national coverage landscape for prostate MRI services, assessing the presence of updated and accurate coverage requirements by private payers.

METHODS:

The database Policy Reporter was used to evaluate 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.

RESULTS:

Overall, 11.1% of payers cover prostate MRI in biopsy-naïve patients with suspected prostate cancer, with the remaining 88.9% requiring 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 staging is covered by most payers, although typically with stringent indications (eg, PSA ≥ 20 ng/mL, Gleason score ≥7 or 8, stage T3 or T4, or ≥20% risk of nodal metastases). Only 10 payers discuss active surveillance, with 8 of these requiring a repeat biopsy before MRI. Coverage for detection of post-treatment recurrence often requires 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.

CONCLUSION:

Prostate MRI coverage varies widely among private payers, fails to recognize major clinical scenarios, is overly restrictive, and is often not reflective of current clinical practice. This creates challenges for patients and referring physicians seeking to obtain ready access to prostate MRI services.

KEYWORDS:

Insurance coverage; medical necessity; private payers; prostate MRI

PMID:
30213713
DOI:
10.1016/j.jacr.2018.07.009
[Indexed for MEDLINE]

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