Court Blocks Aetna from Denying Proton Therapy Coverage

An ailing cancer patient has secured a court order preventing Aetna Life Insurance Co. from denying coverage for his cancer treatment on the grounds that it is experimental.

Plaintiff Bobby B. sought the order after Aetna refused to cover proton therapy to treat his prostate cancer. Due to Bobby’s medical history, his doctors had recommended proton therapy instead of other, more traditional therapies. Other treatment options had been deemed too risky because Bobby also suffers from type-2 diabetes.

Aetna, Bobby’s health insurance provider, denied Bobby’s claim for coverage, claiming that proton therapy is experimental and therefore does not qualify for coverage.

Bobby unilaterally sought and received a court injunction blocking the denial. A spokesperson from Aetna said the company had received no notice of the matter prior to issuance of the injunction. Attorneys for Bobby said Aetna had not responded to their attempts to contact them.

What Is Proton Therapy?

Proton therapy is a new form of radiation treatment that gives physicians much more control over the distribution of radiation. Standard radiation therapy uses X-rays that irradiate all tissue in their path – not just the targeted cancerous tissue, but also the tissue in front of and behind the target along the path of the radiation beam. By applying radiation to healthy tissue, this older method can lead to health problems later.

Using proton therapy allows the physician to be much more precise about where the radiation beam deposits its energy. Unlike with X-rays, a proton beam has a peak point at which it releases the largest amount of its energy. The physician can position and shape that peak point so that it targets the tumor while sparing healthy tissue around it.

According to the National Association for Proton Therapy, this type of therapy has been around since the 1950s and has been in clinical use since 1990. MD Anderson Cancer Center, the facility where Bobby is being treated, has been using proton therapy for almost ten years. The association says that proton therapy is now widely accepted by insurers – including by Medicare and Medicaid, which do not cover treatments considered experimental.

California Insurance Claim Denial

California law provides options for those facing denials of coverage like the one Bobby faced. The California Department of Insurance administers an Independent Medical Review program that provides impartial third-party review for certain types of insurance coverage disputes. Denials for allegedly experimental or investigational treatments qualify for review, as do denials based on questions of medical necessity or claims for urgent or emergency services also qualify for review. Best of all, the reviewer’s final decision is binding on the insurer.

This review process often gives good results for patients. A study by Capital Public Radio found that patients who appeal denials to California insurance regulators win about half the time.

But some insurance coverage disputes may not qualify for California state regulatory review, or the need for care may be too urgent to wait through a slow appeals process. In those cases, patients may have a better option in consulting a knowledgeable insurance attorney.

Join a Free California Bad Faith Insurance Lawsuit Investigation

A bad faith lawsuit investigation has been launched into allegations that some California insurance companies are refusing to pay valid medical claims or offering to pay far less than the claim is worth. Some of the companies being investigated for potential violations include:

• Aetna
• Anthem Blue Cross
• Blue Cross of California
• Blue Shield of California
• Cigna
• Health Net
• Kaiser
• Secured Horizons
• United Healthcare
• WellPoint
• Others

If you or a loved one were denied coverage for autism treatment, mental health treatment, plastic surgery skin removal after weight loss, proton therapy for cancer, or some other medically necessary treatment, you may have a legal claim.

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