Insurance Denials for Proton Therapy Treatment for Cancer Patients

Many patients who are receiving treatment for cancer may pursue proton therapy. This recent development in radiation therapy uses protons instead of X-rays. Since X-rays are known to put patients at risk of additional illnesses, proton therapy is extremely promising with fewer side effects.

However, the availability of this treatment is limited to only a few cancer centers around the U.S. Patients are seeing pushback from their health insurance companies against covering the costs. The Fifth Circuit Court of Appeals recently issued a powerful decision against an insurance provider that reflects the struggles of cancer victims to get the lifesaving help and coverage they need from their insurers.

What Is Proton Therapy?

When administering proton therapy, radiologists use a machine called a cyclotron (or a synchrotron) to speed up protons and direct them in a very targeted manner at tumors. Protons are positively charged particles that can destroy cancer cells when they are sped up to give them high energy. The cyclotron can be more precise than standard X-ray treatments, reaching deeper into the body to treat cancers that affect internal organs.

Although proton therapy uses radiation like many traditional cancer treatments, the protons do not emit additional radiation when they leave the body. This produces fewer side effects and damage, making it a valuable tool for patients fighting cancer. Its limited availability means that patients must usually travel for treatment, in addition to paying an often higher price for the relatively new treatment.

Facing these bills out of pocket can be daunting and usually cost-prohibitive, which is why it’s critical your health insurance provider honors its promise to cover medications and therapies prescribed by your doctors. When insurance companies think they can overrule medical opinions, the carriers can experience stern treatment by the courts when patients must rely on legal action to secure the financial relief they need.

Details of the Case in Question

In the case of Salim v. La. Health Serv. & Indem. Co., Robert Salim purchased health insurance from the Louisiana Health Services and Indemnification Company under the banner of Blue Cross Blue Shield of Louisiana. When he was later diagnosed with throat cancer in late 2018, the company denied his preauthorization request to seek proton therapy, despite the recommendations of his doctors.

Blue Cross claimed the treatment was “not medically necessary,” relying on its internal guidelines and the fact that Mr. Salim had no previous history of cancer. Mr. Salim and his attorneys appealed the denial, and Blue Cross denied it a second time. After a third denial, the patient elected to undergo the treatment to fight his advancing cancer and then sued Blue Cross for failing to pay benefits under the Employee Retirement Income Security Act of 1974 (ERISA).

Blue Cross appealed to the Fifth Circuit Court of Appeals, which ruled that Blue Cross’ denial was not supported by substantial evidence. The court noted that Blue Cross had relied on only one guideline for denying coverage.

Why Were the Blue Cross Denials Wrong in This Case?

Blue Cross relied on outdated policy guidelines when making its decisions on Mr. Salim’s requests for coverage of proton therapy treatment. It claimed its guidelines titled “Radiation Oncology: Proton Beam Therapy” stated that this therapy was not suitable for patients who had head or neck cancers.

Mr. Salim and his lawyers submitted evidence from his doctors and others that indicated the American Society for Radiation Oncology (ASTRO) did, in fact, expressly recommend proton therapy for exactly the type of cancer Mr. Salim had. Despite this material demonstrating Blue Cross’ outdated policies, the insurer repeatedly denied his health insurance coverage, using the same claims reasoning each time.

During Mr. Salim’s ERISA lawsuit against Blue Cross, the court examined the company’s claim that its policy allowed it full discretion in determining benefits. The court ruled in favor of Mr. Salim, stating that Blue Cross abused its discretion in this regard when it denied his coverage for proton therapy. The insurance provider used an outdated interpretation of the ASTRO policy rather than changing its internal guidelines to match new views supported by current medical interpretation.

Why Is This Ruling So Important for Texas Clients?

The Fifth Circuit Court of Appeals is an important part of the United States justice system. It is one of a small number of federal appellate courts that falls directly under the U.S. Supreme Court, so its rulings are both highly persuasive and dominant for every court in its jurisdiction. These states include Texas, Louisiana, and Mississippi.

A health insurance lawyer in Texas can use this opinion to help additional clients who have been denied coverage for proton therapy. While the court’s ruling is very plaintiff-friendly, it is specific to cases involving this treatment and a particular kind of cancer (throat cancer) – although we believe corresponding arguments can be made for the coverage of proton therapy treatment of other types of cancer as well.

What the Fifth Circuit Ruling Might Mean for Your Health Insurance Denial

When Blue Cross took its appeal to the Fifth Circuit Court of Appeals, the insurance giant likely hoped to continue to deny coverage for Mr. Salim and countless other cancer victims. However, the Court found that Blue Cross’ denial was not supported by substantial evidence. The health insurance provider used only a single guideline based on outdated information.

While it was time-consuming and difficult, Mr. Salim pursued his insurer because his doctors verified that his cancer treatment would specifically benefit from proton therapy. The Court recognized that Blue Cross could not hide behind its “discretionary power” while using outdated policies to make real-life decisions that impacted real people, their health, and ultimately, their mortality.

Our experienced health insurance litigation attorneys know they must exercise caution when interpreting this ruling, as it may be construed as a narrow approach to the law. However, the decision may provide an additional means of support in similar cases our legal team manages to ensure our clients get the insurance coverage and financial compensation they deserve.

Fighting a Health Insurance Denial? Contact Berg Plummer Johnson & Raval for Help Today.

When you pay for insurance, you expect it to be there for you when you need it. When health insurance providers use outdated information or unfair discretion to deny payments for your bills, you face additional stress that can make your condition worse and delay the treatment you so desperately need. You need reassurance that your insurer will do what must be done so you can fully recover. Instead of adding the worry of how to hold an insurance company legally liable for its wrongful actions, contact our law firm to handle your insurance litigation and / or ERISA case.

We are powered by teamwork to be successful at trial and during appeals. We have a passion for justice and believe in strong attorney-client relationships so everyone who trusts in us feels valued and important. Our lawyers practice with integrity, compassion, and tenacity to ensure our clients receive the justice and compensation they deserve.

If you need help with an insurance denial for proton therapy treatment as a cancer patient, reach out to us to speak with a qualified health insurance attorney on our team. Our qualified professionals will help you challenge your provider’s denial or low valuation for your benefits. When bad faith is involved, we will take them to court.

To speak with an insurance attorney, contact us to schedule a meeting today.

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