For some California cancer patients, denial of coverage for proton therapy can bar them from accessing a powerful and effective form of cancer treatment.

Proton therapy is a sophisticated form of radiation treatment. It avoids some of the problems associated with other types of radiation therapy.

The invention of proton therapy is credited to physicist Robert Wilson, who first described it theoretically in 1946. By the 1950s, some health care facilities were using it to treat certain types of cancers. In 1990, Loma Linda Medical Center opened the first hospital-based proton therapy center.

Proton therapy uses a beam of accelerated subatomic particles to destroy cancerous tissue. The proton beam damages the DNA in cancer cells in a way that causes the cell to cease functioning. The cell then begins to break itself down through a process known as apoptosis, or programmed cell death.

A significant benefit of proton therapy is that it is extremely precise. Unlike the X-rays used in traditional radiation therapy, the beam used in proton therapy can be shaped to match the size and shape of the cancerous tissue to be destroyed.

The beam can be adjusted so that it does not kill tissue beyond a pre-determined depth inside the body. Thanks to that precision, a proton beam can kill only cancerous tissue while leaving the nearby healthy tissue intact.

Therapy that uses X-rays, on the other hand, is less precise. It may require more than one X-ray beam directed at different angles, all focusing on the cancerous tissue while simultaneously endangering nearby healthy tissue.

Denial of Coverage for Proton Therapy in California

Despite proton therapy’s widely-recognized benefits and its decades-long history of use as a treatment, some California health insurance carriers still deny coverage for proton therapy treatment.

The procedure’s cost may be one reason for denial of coverage for proton therapy. Proton therapy tends to be more expensive than X-ray therapy – close to twice as expensive for certain types of cancer.

The cyclotrons used in proton therapy are costly and difficult to build, and that extra expense translates to increased treatment costs. The expense can also limit the availability of proton therapy to the few facilities that can afford to offer it. Those facilities may be out of network for some patients.

Insurance companies vary in their stated reasons for denial of coverage for proton therapy. Some companies have reportedly contested the necessity of proton therapy, arguing instead that other, less expensive treatments would be just as effective. Others argue that proton therapy is not necessary at all.

Some companies say the providers of proton therapy are not within their network of covered providers. This can make getting coverage for proton therapy tricky for some patients, as there is a limited number of facilities in California like Loma Linda Medical Center that actually offer proton therapy.

Whatever the company’s stated reason for denial, the greater cost of proton therapy raises the possibility that denial of coverage for proton therapy could have been made in bad faith. Checking with a knowledgeable insurance attorney can make the difference between getting coverage for necessary treatment and having to settle for an inferior alternative.