If you or a loved one has been diagnosed with cancer, you are likely feeling overwhelmed. If you receive a notice that your radiation treatment has been denied by your insurance, you may feel desperate, unsure of where to turn or what to do. This is a time in your life when you need a strong legal advocate by your side—someone who will fight for you when you may be unable to fight for yourself. Attorney Scott Glovsky and his legal team are ready to help you get the radiation treatment you need. We will go to the mat for your right to receive the medical care you need to treat your cancer. Our goal is to prevent big insurance companies from getting in the way of your ability to get better.
Why Might a Radiation Treatment Be Denied by Insurance?
Radiation treatments could be denied by your insurance company for a variety of reasons. In some cases, it is a simple matter of a missing form or a form with errors. Denials for these reasons can usually be corrected. Your radiation treatment could be denied by your insurance due to an exception in its policy, or because you failed to obtain pre-authorization as required under your policy. Just as often, however, radiation treatments are denied by insurance companies due to simple economics. When cancer treatment is expensive, big insurance companies may deny the treatment by claiming it is not medically necessary or is experimental or investigational. Although radiation is an accepted form of cancer treatment, there are some forms of radiation that may be denied by your insurance.
Specific Types of Radiations Treatments That Might Be Denied
Radiation treatments—like all medical treatments—have come a long way over the past few decades. Some of the current types of radiation treatments include:
- IGRT (Image-guided radiation therapy) uses powerful energy beams to kill cancerous cells. These energy beams may come from protons, X-rays, or other sources. High-quality images are taken prior to each IGRT therapy treatment and are used to increase the precision and accuracy of the IGRT, making it possible to use higher doses of radiation. The average cost of IGRT is about $17,330 and up.
- IMRT (Intensity-modulated radiation therapy) is an advanced type of radiation treatment that uses a powerful energy beam to kill cancerous cells. The beams are shaped to match the shape of the cancer, moving through an arc while delivering radiation. IMRT can also be used to treat benign cancers throughout the body and is highly targetable to minimize the risk to healthy tissues. The median cost for IMRT is about $16,343.
- PBRT (Proton beam radiation therapy) is one of the newest radiation treatment options, treating tumors with protons instead of photons that release all their energy in a burst that is delivered directly to the tumor. Proton beam radiation therapy is especially useful for targeting cancerous tumors that are close to sensitive areas and for treating cancer in children. PBRT can be used to treat prostate, eye, head and neck, cranial-spinal, lung, liver, and breast cancer tumors. Most of the PBRT systems in use today were extremely expensive to build because the technology requires football field-sized facilities. As a result, there are only about 30 PBRT facilities across the United States. The median cost of PBRT is $54,706.
- SBRT (Stereotactic body radiation therapy), is a radiation treatment for cancer that delivers intense, extremely precise doses of radiation while minimizing the damage to healthy tissues. The median cost of SBRT is $27,145.
- SpaceOAR is a polyethylene glycol hydrogel that has been shown to minimize urinary, sexual, and bowel side effects while protecting the quality of life for prostate cancer patients undergoing radiation therapy. The cost of a SpaceOAR hydrogel injection is about $7,557.
What Should You Do if Your Radiation Treatment Is Denied by Insurance?
For radiation denied by insurance, it is imperative that you take immediate action. Understandably, at a time when you are battling cancer, you may not feel like going to war with an insurance company to get the treatment you need and deserve. This is where the Law Offices of Scott Glovsky can help. We will fight for your right to get the radiation treatments your doctor believes will give you the best chance of a long, healthy life.
We may ask that you obtain a letter from your doctor that states the reasons your radiation treatment is medically necessary. If necessary, we will help prove that the radiation treatment is neither experimental nor investigational. We will guide you in filing an internal appeal with your insurance company, giving it the chance to reverse its original denial. If this is unsuccessful, we can provide guidance in a third-party appeal. The decision of this third-party appeal must be honored by your insurance company.
What Insurance Companies Are More Likely to Deny Radiation Treatment?
Radiation therapy for the treatment of cancer may be denied by any insurance company, although Anthem is the latest insurance company to face a lawsuit over the denial of coverage for proton beam radiation therapy. In March 2023, Aetna lost a class action over proton radiation therapy denials and was required to pay $3.4 million. The following California insurers may deny coverage for radiation treatment or other cancer treatments:
What Type of Radiation is Frequently Denied?
Proton beam therapy is a type of radiation too often denied by insurance in many cases. Some insurers claim proton beam therapy is an elective procedure that is unnecessary, or that it is still experimental. Proton beam radiation is often recommended by medical professionals as a standalone treatment, or to complement chemotherapy and/or surgical procedures.
Proton beam therapy uses a cyclotron or synchrotron that accelerates positively charged protons, making them viable for the destruction of cancer cells. This type of radiation does not affect surrounding healthy skin and organs, making it considerably safer than other types of radiation therapy. Because proton beam therapy is a valid cancer treatment that saves lives, it could be insurance bad faith when an insurer denies this treatment.
What’s the Process Following an Insurance Denial?
The first thing you should do following radiation denied by insurance is to review your policy and paperwork, particularly the summary of benefits in your insurance documents. Re-read the letter your insurance company sent when it denied your claim, which should also outline the appeal process. From this point, you can do the following:
- Call your insurance company if you have questions.
- Keep meticulous records including the name of each person you speak with, the date, and the decision or outcome.
- Contact your doctor’s office for a letter that states why the treatment is medically necessary.
- If you get health insurance from your job, you may want to speak to your company’s health benefits manager.
- Educate yourself regarding the appeals process, being especially cognizant of all deadlines.
- File an internal review appeal, asking the insurance company to have another look at your claim. If your health is in immediate jeopardy, you can ask for an expedited appeal. You might speak with an attorney who focuses on health insurance denials for guidance.
- If you are unhappy with the outcome of the internal appeal, your attorney might recommend filing a third-party external appeal where your claim will be looked at by those who do not work for the insurance company. In some cases, an attorney might recommend taking legal action instead of pursuing a third-party appeal.
What Can You Do to Help Your Attorney Fight Your Claim Denial?
To help your attorney fight your radiation denied by insurance, the best thing you can do is to keep comprehensive records every step of the way. Make sure you have all paperwork associated with the claim denial, including any medical receipts, your policy paperwork, and your list of every step you’ve taken and every person you’ve spoken with. Any paperwork that you’ve received in the mail should be forwarded to your attorney. Make sure you keep copies of everything.
How the Law Offices of Scott Glovsky Can Help When Your Radiation is Denied by Insurance
Attorney Scott Glovsky can help with your radiation denied by insurance because he once worked for large corporate law firms, defending insurance companies. This gives Scott a unique perspective, allowing him to anticipate every tactic the insurance company may use to avoid paying a valid claim. Scott is highly respected in the industry, receiving many referrals from other attorneys who are aware of his expertise in insurance claim denials.
Scott carefully chooses each case because he devotes a tremendous level of time and care to every client, getting to really know the client, their families, and the story behind their suffering. When you choose the Law Offices of Scott Glovsky, you are not selecting an “assembly line” law firm that will delegate your case to a junior associate or paralegal. Contact attorney Scott Glovsky today for the highest level of care and support.