Have you or a loved one received a Proton Radiation Therapy Health Insurance Denial? We Can Help
Proton Radiation Therapy (PRT), sometimes called “Proton Beam Therapy” or “Proton Therapy” is a form of radiation that uses high-powered protons instead of x-rays. The FDA approved this therapy to treat cancer in 1988. PRT treats both cancer and noncancerous tumors. Considered by some as safer and more effective than x-ray radiation, PRT is expensive. If you receive a proton beam therapy denial, contact the Law Offices of Scott Glovsky.
What is Proton Radiation Therapy?
PRT is a type of radiation that utilizes high-powered energy instead of x-rays to treat both cancer and noncancerous tumors. Proton Radiation Therapy sends protons to and irradiates a very specific part of a tumor. The protons travel as fast as 2/3 the speed of light. A proton at high energy often destroys cancer cells. The energy is not released until it hits the tumor.
What Health Concerns Does Proton Beam Therapy Treat?
Physicians prescribe Proton Therapy for many types of cancers including breast, liver, lung, prostate, pancreatic, bone, lymphoma, and others. They use it for tumors on, near, or impacting the brain, head, neck, skull, spine, pituitary glands, and the eyes. It also treats sarcoma and other types of cancers like esophageal cancer. PRT is helpful in treating cancers in kids because it can target cancer without harming other cells in their growing bodies. Finally, because it is so targeted, PRT treats tumors but not cancer that has spread elsewhere in the body.
How and Where is Proton Radiation Therapy Administered?
Just like x-rays, an external machine sends proton radiation through the skin and into the body. PRT is typically but not always an outpatient procedure in a non-hospital facility. Some facilities have “gantry” machines. The gantry rotates around the patient, and protons are delivered through its nozzle. Magnets direct the protons to the tumor. The medical equipment used for PRT is quite expensive, and thus proton radiation therapy denial happens.
What is the Benefit of Proton Therapy Versus Traditional X-Ray Therapy?
PRT seems to be more effective and safer than traditional X-Ray radiation therapy. The reason is that it sends a higher dose of radiation to a very precise area of the tumor. X-ray radiation, on the other hand, is not as targeted and may damage surrounding tissues, organs, and nerves. PRT, like x-rays, is also noninvasive and painless.
Proton Therapy is believed to have fewer adverse events because it is so targeted to the tumor. X-ray radiation, in contrast, delivers radiation outside the tumor and continues to emit radiation as it exits the body. In doing so, the radiation harms healthy tissues close to the tumor and can trigger side effects. Also, due to fewer side effects, PRT gives a better quality of life both during and post-treatment. In some cases, PRT works where traditional x-ray therapy already failed. Finally, Proton Beam Therapy is proven to treat several different types of cancers.
When Does a Doctor Recommend Proton Radiation Therapy?
Proton Therapy is typically given when there are tumors close to critical areas like the spinal cord, eyes and brain. Since it is so targeted, it is helpful for tumors that have not yet spread. Sometimes doctors prescribe it after traditional x-ray radiation failed.
What is the Cost of Proton Radiation Therapy?
PRT is much more expensive than x-ray therapy. PRT may cost from $30,000 to $120,000. The specific cost depends on the duration of the treatment as well as the location and size of the tumor. A course of Intensity-Modulated Radiation Therapy (IMRT) costs around $15,000. For this reason, sometimes health insurers want policyholders to start with IMRT, and can create proton radiation therapy denial cases.
What are Alternatives to Proton Beam Therapy?
There are three types of stereotactic radiosurgery (SRS) – CyberKnife, proton beam, and Cobalt-60-based using photons. All three are “linear accelerators” and each technology provides high-energy radiation to treat some types of cancers. These technologies all deliver radiation to a targeted area of a tumor thus minimizing side effects.
IMRT is a form of radiation therapy where the strength of the radiation beam is modified to match the shape of a tumor to minimize the damage to surrounding tissue. But IMRT uses x-ray radiation.
Do Insurance Companies Cover Proton Beam Therapy?
Medicare, the federal government’s health insurance plan for those aged 65+, typically covers Proton Therapy. In fact, Medicare usually only covers medications and treatments that are FDA-approved. That said, Medicare’s coverage may vary based on the state and specific disease. Medicare often pays up to 80% of the approved costs for eligible people. Medicare covers these individuals through Part A if given inpatient and through Part B if given outpatient. Secondary health insurance coverage like Medigap may assist with financial obligations. Medicaid, known as Medi-Cal in California, coverage of Proton Therapy is similar to Medicare coverage.
Some insurers treat PRT as experimental/investigational while others consider it medically necessary, and this is why proton radiation therapy denial happens.
Is Proton Beam Therapy Medically Necessary Or Medically Beneficial?
Many commercial insurance companies require prior authorization for proton therapy. When approved by the insurer, Proton Beam Therapy is considered medically necessary. Medically necessary essentially means this therapy is necessary to treat a policyholder’s tumor. It can be challenging to get your insurer to make this determination. It often takes time, persistence, and assistance from your doctor.
When your insurance company claims Proton Therapy is medically beneficial but not necessary, it is saying that other treatments can also treat your tumor. Typically, these other treatments are less costly than Proton Radiation Therapy, and proton radiation therapy denial will happen.
Often health insurers make a patient adhere to step therapy, also known as “tried and failed” or “fail first.” Step therapy requires the policyholder to begin an alternative therapy instead of the doctor-prescribed treatment. If alternative therapies don’t work, the insurer will assess the situation usually after 60 days. Of course, the problem with therapies such as x-ray radiation is that the radiation may damage healthy tissues and organs. In addition, it may not work.
How Do Insurance Companies Evaluate Proton Radiation Therapy Coverage Requests?
Each commercial insurance company is different. The reason is that they have unique medical or pharmacy policies that establish the guidelines for assessing coverage requests. Each insurer examines the FDA’s approval of Proton Therapy to create its own clinical policies. Internal clinical policies guide decisions on medical necessity. In addition, outside practitioners evaluate the internal policies to determine their appropriateness. But their guidance might be influenced by different factors such as money or the possibility of employment with the insurer. Because of outside influences, these doctors may approve overly restrictive internal clinical policies.
The challenge with overly constrictive policies is that insurers rely on them to determine whether a therapy is medically necessary or experimental/investigational. The doctor relies on peer-reviewed medical publications and experience with other patients who have similar conditions to determine the optimal treatments.
What Can You Do If You Receive A Proton Radiation Therapy Health Insurance Denial?
You have many options after receiving a denial. The first step is often to appeal the decision with your health insurance company directly. But before you do, you should know whether you have an ERISA plan or a non-ERISA plan. ERISA is the Employment Retirement Income Security Act of 1974. Most people don’t know whether their plan is ERISA or non-ERISA. The best thing to do is to ask your plan administrator who is often part of the Human Resources department.
Usually, if you are insured through a private employer, you have an ERISA plan. But this is not always the case. Non-ERISA plans include the following:
- government employer plans
- religious group plans
- private employer plans that only include business owners
- family and individual plans through Covered California
- Family and individual plans bought through private insurance companies including Kaiser Permanente, Anthem Blue Cross, Blue Shield of California, and others
If you have an ERISA plan, we recommend that you speak with a qualified health insurance lawyer before you file your appeal. We have a lot of helpful resources on our website. Go here to learn more about the ERISA appeals process. If you are a member of a non-ERISA plan, you have many options. Start with the reason for your denial. Go here to learn more about non-ERISA appeals.
