Proton beam therapy is covered by Medicare, Medicaid, and many private insurance companies. Coverage is determined on a case by case basis depending on your diagnosis, medical history and other factors.
It’s essential that you and your primary oncologist submit a request for coverage of your proton therapy plan prior to scheduling treatment to learn about your coverage. Many providers cover proton therapy, but not all.
A case against Blue Cross Blue Shield (BCBS) and Health Care Services Corporation was removed to Oklahoma federal court Friday. The suit comes following allegations that the insurance giant improperly denied coverage to the plaintiff for a cancer treatment using proton beam therapy. The plaintiff is seeking both punitive and compensatory damages.
The plaintiff was insured by BCBS under an individual health insurance policy, the complaint said. In August of 2019, he was diagnosed with anal cancer. Following his diagnosis, his doctors recommended that Proton Beam Therapy Radiation (PBT) would be the most effective course of treatment for his condition. After proceeding with the treatment, the plaintiff submitted an insurance claim requesting coverage of the PBT. His initial claim was denied by the defendants.
The plaintiff said he appealed this initial denial of the claim in August 2019 using both a standard appeal and an external review appeal. In these, he said he included letters from “MD Anderson Cancer Center in support of coverage for the recommended treatment.” Both of these appeals were denied by the defendant on August 30, 2019, according to the plaintiff.
These denials have purportedly continued despite the Plaintiff claiming that he “complied with the terms of the insurance policy required for coverage” and submitted the claims in a correct and timely manner. Since the plaintiff had an insurance policy with the defendant, BCBS had specific obligations to the plaintiff, specifically for coverage of “medically necessary treatment.” The plaintiff had doctors defend his condition, explaining that his treatment for the cancer was medically necessary through the “submission of evidence and information.”
Despite this, the complaint said, the defendants have continually failed to cover the PBT treatment. The plaintiff asserted that this was “unreasonable, improper, and in violation of the terms of the Policy.” He also argued that BCBS breached their contract with the him, leading him to seek damages of $75,000, interest, litigation fees, and any other relief deemed necessary and just by the court.
The plaintiff is represented by Dewitt, Paruolo & Meek. The defendant is represented by Crowe & Dunlevy.
This week, Blue Shield of California announced that it will reduce coverage of a type of cancer treatment called proton beam therapy, the Los Angeles Times reports.
Details of Proton Beam Therapy
The therapy method uses as cyclotron to speed protons up to nearly the speed of light. The protons then form a beam about the width of a pencil that can target cancer cells with greater precision than traditional radiation treatments.
According to the Times, such accuracy can be especially helpful in cases when tumors are near a patient's eye, brain or other crucial organs.
Medicare pays more than $32,000 per proton beam treatment, compared with less than $19,000 for each traditional radiation treatment.
However, several studies have found that proton therapy does not produce better results than traditional radiation.
Details of Blue Shield's Decision
Blue Shield said that it only will pay for proton beam therapy in cases where clinical evidence supports its use, such as for certain tumors in children.
Marcus Thygeson -- a physician and chief health officer at Blue Shield -- said, "The real issue here is the growth of these expensive new technologies that drive up the cost of health care when there is no evidence of improved outcomes," adding, "It's important we set limits on their use so we can achieve a high-quality health care system but also an affordable one."
The policy change comes as Scripps Health in San Diego prepares to open a $230 million proton beam therapy center this year, the second such facility in the state.
Scripps Health's Reaction
Scripps officials said that limiting coverage for proton beam treatments fails to acknowledge that such therapies can reduce health care costs over time.
Chris Van Gorder -- CEO at Scripps Health -- said, "An insurance company looks at the short term. They are not concerned with the long-term cost impact because the patient may be with a different insurance company later" (Terhune, Los Angeles Times, 8/28).
This is part of the California Healthline Daily Edition, a summary of health policy coverage from major news organizations. Sign up for an email subscription.