Payers Create CAR-T Approval Systems as Adoption Increases

Spurred by CMS’s decision to cover chimeric antigen receptor T-cell therapies under Medicare, commercial payers are beginning to systematize approvals for CAR-T treatment as use of these breakthrough cancer therapies is beginning to ramp up, experts say.

“Despite the costs of CAR-T, I know many plans were already looking at providing coverage prior to the CMS decision,” which was released in October 2019, says Dan Danielson, R.Ph., senior director of the access experience team at PRECISIONvalue. “CMS’s decision provided confirmation that they were on the right track,” he tells AIS Health, a division of MMIT.

Following the CMS changes, many health plans subsequently updated their medical necessity guidelines around T-cell therapies, adds Ashraf Shehata, national sector lead for life sciences at KPMG.

Case History Will Drive Authorizations

“There’s probably some space between case-by-case approvals and what I would call process-based approvals,” Shehata tells AIS Health. “They still need quite a bit of documentation. They have to make sure that the person has no prior treatment with CAR-T, proper organ function, no active infection, no history of allergies around stem cell transplant. And then we’ve seen a lot more visibility on the approvals of the treatment facility itself. Those parts of the process have been much more consistent.”

© 2021 MMIT

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