Lawsuits for Prostate Cancer Patients Denied Coverage for Proton Therapy

Attorneys working with ClassAction.org are investigating whether class action lawsuits can be filed on behalf of patients who were denied coverage for proton beam radiation therapy for the treatment of prostate cancer.

It is believed some patients are being wrongfully denied coverage for this treatment despite overwhelming evidence of its efficacy and ongoing support from the medical community. As a result, these individuals are getting stuck with thousands of dollars in medical bills or are being forced to explore less effective methods of treatment for their prostate cancer.

Why Are Health Insurance Companies Denying Coverage for Proton Therapy?

It is believed patients are being denied coverage for proton beam radiation therapy because, on average, it’s significantly more expensive than intensity modulated radiotherapy.

Some patients are being told that proton therapy is excluded under policyholders’ coverage because it’s “experimental,” “investigative,” or “unproven” even though it has been a well-accepted method of treatment for more than 30 years.

In 1988, the FDA approved proton beam radiation therapy for the treatment of prostate cancer and many detailed peer-reviewed studies since then have validated its safety and efficacy. Further, many oncologists recommend proton therapy over traditional intensity modulated radiotherapy because it is more effective, does less damage to healthy tissues and organs, and has fewer complications. Proton therapy is even covered under Medicare as a safe and effective treatment for prostate cancer. Still, some companies may be ignoring this information and even go so far as to disregard letters from patients’ doctors regarding the efficacy and necessity of the treatment.

United Healthcare Sued Over Proton Therapy Denials

Insurance company United Healthcare was hit with a class action lawsuit in April 2019 over its alleged denial of proton therapy coverage for patients with prostate cancer. The plaintiff in the case says the company denied his request for pre-authorization for the treatment because it fell under an exclusion in his plan titled “Experimental or Investigational or Unproven Services” and therefore was not a covered therapy for patients over the age of 18. Despite this denial, the plaintiff decided to go ahead with the treatment – with positive results – and paid out of pocket for it.

The plaintiff says he exhausted all internal appeals to get United Healthcare to overturn its decision. United Healthcare’s response to the plaintiff’s request, the suit says, was to uphold its denial of coverage based solely on its standing policy for proton beam therapy and “without considering the substantial materials submitted by the plaintiff and his providers supporting coverage.” When the plaintiff filed an external appeal with the Medical Review Institute of America – an “independent” review organization chosen by United Healthcare – it also upheld the denial “without conducting a truly independent evaluation of whether proton beam radiation therapy is a proven and effective treatment for prostate cancer,” according to the lawsuit.  

In January 2019, United Healthcare changed its policy and declared proton therapy a proven treatment for prostate cancer; however, it is allegedly failing to retroactively apply this new policy. The suit pegs the switch as “arbitrary,” as no significant clinical developments had been made between May 2018 – when the company rejected the plaintiff’s claim – and the time the new policy took effect.

It's possible that United Healthcare is not the only company allegedly denying coverage for proton beam radiation therapy.

How Could a Class Action Lawsuit Help Me?

A lawsuit could help you recover money paid out of pocket for your treatment, as well as other damages related to your insurance company’s decision to deny coverage of proton therapy. A court could also order the company to change the way it handles claims for proton therapy. 

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