Approval of Proton Beam Therapy Treatment Allows Client to Receive Liver Transplant

In recent years, proton beam therapy has emerged as a promising treatment option for various cancers, offering precise targeting of tumors while minimizing damage to surrounding healthy tissues. However, despite its potential benefits, many insurance companies have been hesitant to cover this advanced form of radiation therapy. Recently, Raval Trial Law was able to get UnitedHealthcare to reverse its wrongful denial of proton beam therapy for a client. In turn, this allowed him to receive a liver transplant that would not have been possible under other cancer treatment.

The Promise of Proton Beam Therapy

Although standard radiation therapy effectively controls many cancers, it also delivers damaging radiation to healthy tissues and organs. Proton beam therapy uses protons to deliver a curative radiation dose to a tumor, while reducing dose exposure to healthy tissues and organs. It results in fewer complications and side effects than traditional radiation therapy. With proton therapy, protons deposit their energy over a very small area called the “Bragg peak.” The Bragg peak can be used to target high doses of proton beams to a tumor, while doing less damage to normal tissues in front of and behind the tumor. Proton beams enable patients to tolerate higher doses of radiotherapy compared with the photon beams used for traditional radiation therapy. The proton beam can be adjusted and formed to match the size and shape of the cancerous tissue to be destroyed, while not killing healthy tissue beyond a pre-determined scope and depth. The cancer cell then begins to break itself down through a process known as apoptosis, or programmed cell death. Proton therapy has been approved by both the FDA and Medicare as an effective cancer treatment.

Why Insurance Companies Deny It

Despite its advantages, proton beam therapy is often more expensive than conventional radiation therapy. Insurance companies create guidelines to ensure that treatments they cover are cost-efficient. At Raval Trial Law, we have dealt with numerous proton beam therapy denials. Here are several reasons why insurance companies most commonly deny proton beam therapy:

1. Lack of Clinical Evidence:

Insurance companies typically require robust clinical evidence demonstrating the effectiveness of a treatment before they will provide coverage. While proton therapy has shown promising results in certain cases, there may be insufficient long-term data or randomized controlled trials comparing it directly with conventional therapies for all types of cancer. This lack of comprehensive evidence can lead insurers to deny coverage until more data becomes available. Of course, proton therapy has been approved by both the FDA and Medicare as an effective cancer treatment, undercutting this position.

2. Cost Considerations:

The high cost of proton beam therapy is a significant barrier to insurance coverage. Building and maintaining proton therapy facilities requires substantial financial investment, which translates into higher treatment costs. Insurance companies may be reluctant to cover these expenses, especially when less expensive treatment alternatives exist. Again, however, many insurance companies have actively invested in the building of these centers around the country, undercutting this position.

3. Coverage Policies and Guidelines:

Insurance policies often dictate coverage based on established treatment guidelines and protocols. If proton therapy is not specifically listed as a covered treatment option or if it falls outside of defined criteria (such as for certain types or stages of cancer), insurers may deny coverage on the grounds of policy restrictions. It is important to note, however, that insurance companies create their own guidelines. They may or may not follow national guidelines recognized by the medical community.

The Latest Case

For patients like our client who face a cancer diagnosis, navigating insurance denials for proton beam therapy can be emotionally and financially daunting. It often requires advocacy from healthcare providers and appeals processes to secure coverage or explore alternative funding options. Here, our client was forced to spend over $100,000 out of his own pocket to cover the cost of proton beam therapy, which was needed to save his life and preserve his organs from the damage that conventional radiation would have caused. After he got the treatment, he came to Raval Trial Law to file an appeal with UnitedHealthcare.

UnitedHealthcare initially refused to respond to our requests for information and documents. This led to a lawsuit just to obtain the documents necessary to file an internal appeal to UnitedHealthcare. The internal appeal was ultimately successful, and it retroactively paid all of the proton beam therapy treatment. Because he obtained the treatment, our client was able to minimize damage to his internal organs, which kept him as an eligible candidate for a liver transplant. After just a few months, we are happy to report that he recently received that lifesaving liver transplant.

Conclusion

While proton beam therapy holds immense promise in improving cancer treatment outcomes, insurance companies continue to deny covered claims. As medical research continues to evolve and more data on proton therapy outcomes becomes available, it is hoped that insurance policies will adjust to reflect the growing understanding of its benefits.

In the meantime, patients and healthcare professionals must work together to ensure that the most appropriate and effective treatments are accessible to those who need them most. When those claims are denied, contact Raval Trial Law for help.