Robert J. Boumis  |  August 28, 2014

Category: Consumer News

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cancer-treatment-stethescopeProton beam therapy, a type of new cancer treatment, is receiving pushback from California insurance companies that refuse to cover the expensive procedure. A recent article by Austin B. Frakt, PhD, of the Journal of the American Medical Association, recently highlighted some of the issues related to the controversy.

Proton beam therapy is a type of radiation therapy that fires a beam of radiation at cancerous tumors, making it an ideal treatment for tumor-based cancers such as prostate cancer, head and neck cancer, esophogeal cancer, liver cancer, lung cancer, lymphoma, sarcomas, and pediatric cancers.

Proton therapy was designed to target tumors more specifically, causing less damage to the surrounding tissue. In theory, this would translate to fewer side effects for patients. But the procedure typically costs much more that other forms of radiation cancer therapy, and several major California insurance companies have questioned proton beam therapy’s effectiveness.

Blue Shield of California announced last year that it will refuse insurance coverage for proton cancer therapy for early-stage prostate cancer patients. California insurers Aetna and Cigna have also stopped covering proton beam therapy for prostate cancer. These insurers and others continue to deny insurance claims for other types of proton cancer treatment. These proton beam claim denials have led to a growing number of bad faith claim denial lawsuits from cancer patients.

The companies have cited studies that indicate that despite the fact that proton beam therapy costs tens of thousands more dollars than other forms of radiation therapy, it gets roughly the same results, with the same level of side effects. But some doctors are arguing against these policies, claiming that denying insurance coverage for these procedures is bad faith.

Bad faith is a legal term meaning that one party in a contract is trying to get out of their obligations. In insurance law, it usually means that an insurance company is trying to avoid paying out on a legitimate claim.

Some physicians have questioned the decision to refuse to pay for proton therapy. In a Los Angeles Times article, officials form the Scripps Health in San Diego have alleged that insurers are cherry-picking articles that support their view, and that longer-term studies back proton beam therapy. On Scripps executive went as far as to say that insurance companies “…are not concerned with the long-term cost impact because the patient may be with a different insurance company later.”

Dr. Frakt’s article states that there are historical precedents for this situation, largely falling on the side of “experimental” treatments.

For example, bone marrow transplants were experimentally used to treat breast cancer. When insurance companies took the issue to court, the courts ruled in favor the experimental treatment.

While it ultimately turned out that bone marrow transplants were not an effective treatment. One the determining factors is that new technologies can quickly become the “accepted standard of care,” which prevents insurance companies from refusing to pay for a treatment.

To this end, the fact that Medicare still covers proton therapy could be used to argue that proton beam therapy is the accepted standard of care.

How to Get Help for Proton Therapy Insurance Denials

Insurance attorneys have seen a rising number of bad faith claim denials from California health insurers. If you or your family member were denied coverage for proton cancer therapy, you may have a legal claim.

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