For patients who have done extensive research into the types of treatments available to address prostate cancer, often they will come across proton beam radiation therapy as an option.

Upon finding out that proton beam therapy allows less radiation to reach nearby tissues, prostate cancer patients are encouraged over the idea. However, denial of coverage for proton beam therapy by insurance companies, like anthem Blue Cross in California, makes it impossible for most patients to even consider this potentially less damaging treatment.

What Is Proton Beam Radiation Therapy?

Proton beam radiation therapy is a newer type of radiation therapy that uses a specific and focused radiation to directly target the tumor in question. Protons, or positively charged particles, are part of the strong beam that is aimed directly at the tumor.

Unlike traditional x-ray therapy, also referred to as radiation therapy, the surrounding tissue is less likely to be damaged during proton beam therapy. X-ray therapy cannot be concentrated as easily to a specific point, and this surrounding tissue is affected by the radiation. This may cause additional damage in certain individuals.

Denial of Coverage for Proton Beam Therapy by Insurance Companies

Early on, treatment of prostate cancer was encouraged by proton beam therapy results. However, over time, more and more insurers are engaging in denial of coverage for proton beam therapy for prostate cancer because it has a higher cost than traditional radiation therapy with similar results in terms of eradicating cancer.

One insurance company that has engaged in denial of coverage for proton beam therapy for prostate cancer is one of the largest health insurance providers in California – Anthem Blue Cross.

While Anthem does indicate that it covers proton beam therapy for certain conditions, such as brain tumors or tumors on the spinal cord, it specifically excludes coverage for prostate cancer.

Anthem Blue Cross goes into great detail on its website about coverage for prostate cancer. Essentially, anthem Blue Cross stands behind a denial of coverage for proton beam therapy saying that studies do not support its superiority over other methods to treat prostate cancer.

“To summarize, while much of the evidence suggests that PBRT is safe and may provide effective tumor control in men with prostate cancer, this evidence is derived from retrospective analyses conducted at a limited number of research centers or from studies with a low level of evidence and other methodological limitations. There is insufficient evidence from the available clinical trials to determine whether PBRT is equal or superior to conventional photon radiation therapy, 3D-CRT or IMRT, and who would benefit most from each type or combination of radiotherapy for the treatment of prostate cancer. “

Several years back, Chris van Gorder, chief executive of Scripps Health in San Diego California told the Wall Street Journal that routine denial of coverage for proton beam therapy for certain conditions was based more on price than on suitability for treatment.

The article states “The decision reflects ‘a very short-term mind-set’ that is overly concerned with the treatment’s price tag.” Van Gorder goes on to say “This is an example of an insurance company injecting themselves in the middle and making a decision as to what’s best for the patient and their physician.”

Your Options after Facing Denial of Coverage for Proton Beam Therapy in California

If you have experienced denial of coverage for proton beam therapy in California, you may be eligible to file a lawsuit against the insurance company. And experienced attorney can review your case at no charge and can help advise you on the legal options that are available to you.