By Ben Frank, Unity HealthTech
Prior authorization has always been a pain point in oncology, but for proton therapy, the stakes feel even higher. Decisions made by payers affect whether patients can access cutting-edge, life-saving care, and whether practices can keep their treatment pipelines running smoothly.
Over the past year, the landscape has shifted in meaningful ways. Payer policies, approval rates, and diagnosis-specific trends now look very different from even two or three years ago. If you run a proton therapy center or manage prior authorization for one, these changes matter. The difference between a smooth approval and a drawn-out denial can mean weeks of stress for patients and thousands of dollars for practices.
So, what’s new, and how can providers adapt? Let’s break it down.
The Big Picture: Why 2025 Feels Different
Over the past year, several forces have collided to push insurers toward reform:
- Legal settlements are pushing payers like UnitedHealthcare (UHC) and Aetna to remove blanket denials for proton therapy after facing lawsuits over outdated ‘experimental’ labels.
- National advocacy from ASTRO and the National Association for Proton Therapy (NAPT) continues to align coverage criteria with clinical consensus.
- State legislation in places like Louisiana now requires insurers to cover proton therapy when ASTRO guidelines recommend it.
- Industry pledges led by (AHIP) America’s Health Insurance Plans commit major payers to faster electronic prior authorization systems and clearer criteria, aiming for real-time decisions on most requests.
These pressures are collectively shifting prior authorization from a blunt gatekeeping tool toward a more transparent, data-driven process.
Key Policy Updates by Major Insurers
The big commercial insurance players such as UHC, Aetna, Cigna, and Anthem/Blue Cross plans, have all recently made changes worth noting:
- UHC: After a $9 million proposed settlement in May 2025, it is looking like UHC will remove its list of 13 diagnoses automatically deemed ‘not medically necessary,’ including prostate, primary brain, and cervical cancers. Now all proton therapy requests require individualized review, with denials based on blanket exclusions largely eliminated.
- Aetna: Following its 2023 class action settlement, Aetna now has one of the broadest coverage policies, routinely approving proton therapy for head and neck, CNS, mediastinal lymphomas, ocular tumors, sarcomas, pediatric cancers, and more.
- Cigna/Evernorth: Expanded its ‘Group 1’ indications in 2024 and now incorporates NCCN and ASTRO guidelines directly into its medical policies, resulting in fewer outright denials for appropriate cases.
- AIM: AIM revised its guidelines in early 2025 to require patient-specific comparisons to IMRT only when a request falls outside ASTRO or NCCN criteria. Blanket denials are becoming increasingly less common, especially in states mandating coverage alignment with national guidelines.
For providers, this means many historically challenging diagnoses – especially in CNS, sarcoma, and re-irradiation cases — now have clearer, evidence-backed approval pathways.
Updates in Payer Approval Rates
One of the most striking updates from our data is the wide gap in approval rates among payers. Some are quietly getting it right, approving the vast majority of requests without unnecessary roadblocks.
For example, we’re seeing more than 90% approval ratings (through all levels of appeal) for a few of the large BCBS plans. These payers demonstrate that high approval rates are possible, even for complex proton therapy cases.
On the flip side, some payers remain bottlenecks. Broadly speaking, the pension Fund based plans we’ve interacted with, approve only 31% of cases (Unity Healthtech Data, 2025), pointing to systemic issues in either their workflows or policy alignment. For providers, this means knowing your payer mix isn’t just helpful, it’s essential for predicting workload and setting patient expectations.
Why Tumor Site Matters More Than Ever
It’s not just who the payer is; it’s also what kind of case you’re sending. Tumor site-specific data shows approval rates can swing dramatically depending on the diagnosis.
In our experience, for Medicare Advantage (BUCA administered), only 33% of central nervous system (CNS) cases get approved, while thoracic cases see an 89% approval rate (Unity Healthtech Data, 2025). That’s a huge gap that doesn’t correlate with model policies or national guidelines.
For practices, this creates two clear action steps:
- Strengthen appeal arguments for high-denial diagnoses like CNS and sarcoma cases, where coverage criteria are often vague, broadly worded, or inconsistently applied. Make sure to reference the most up to date clinical research and any relevant model policies or national guidelines.
- Educate referring physicians about cases that are likely to face scrutiny so documentation can be airtight from the start.
The more data you have on diagnosis specific trends, the more prepared you’ll be to push back when a denial doesn’t align with established standards of care.
Using High-Performing Payers and Data as Leverage
Here’s a strategy many centers overlook: use data from high-performing payers to challenge the laggards.
When one payer approves 97% of proton cases and another payer routinely denies similar cases, you have hard evidence that approval is both possible and standard practice elsewhere.
This isn’t just theoretical. Some centers have successfully used comparative data to push payers toward faster approvals or more consistent coverage policies. In other words, the best-performing payers don’t just set a benchmark, they can be used as leverage in payor conversations. Remember, payors are spending money fighting denials and are always looking for ways to streamline their processes. Be transparent and make sure they know when they are falling behind or when you are consistently overturning their denials at the Independent Review Organization (IRO) level.
Practical Tips for Providers
So, what can proton therapy centers and oncology practices do today to navigate this changing landscape?
- Track your own data: Know approval rates by payer, diagnosis, and stage of appeal. Patterns emerge quickly when you have the right metrics.
- Invest in stronger documentation: Robust clinical notes and supporting literature can make or break an appeal.
- Train teams on payer-specific quirks: Each payer has its own workflows. The more your staff understands them, the faster they can move cases through.
- Build relationships with payers: Sometimes a direct line of communication can shorten turnaround times and resolve borderline cases.
- Know the law: Know federal ERISA law like the back of your hand. Remember a large portion of commercial cases are governed under ERISA rules. Also, every state can have different rules so make sure you’re familiar with local insurance regulations as they relate to prior authorization timelines.
How Technology Can Help
Modern platforms are stepping in to make this process less painful. Unity, for example, gives practices real-time data on approval trends by diagnosis and payer. Instead of manually tracking every denial, centers can see where problems are happening and address them proactively.
Looking Ahead
Prior authorization in proton therapy isn’t going away, but it is evolving. Approval rates are improving with some payers, diagnosis specific data is better than ever, and practices now have enhanced tools to fight back against unnecessary delays.
For providers, the message is clear: use data, stay proactive, and don’t accept denials as the final word. With the right approach (and the right technology) centers can spend less time battling paperwork and more time focusing on what really matters: delivering world-class cancer care.
