You’ve been diagnosed with prostate cancer and decided that proton beam therapy is the
best treatment choice for you. The problem is, your health insurance provider has denied
coverage for the therapy. What do you do next?
Hundreds of men have successfully appealed their insurance companies’ denials for
proton beam therapy coverage, and there is a good chance that you will be able to do it,
too. Winning an appeal takes patience, persistence and a good understanding of why
proton beam therapy is a viable treatment option. This guide provides various tips and
strategies to help you strengthen your case.
About Proton Beam Therapy
Proton beam therapy is a precise, noninvasive treatment that targets cancer with minimal
side effects. By shaping a beam to match the specific shape of a tumor, physicians can
precisely target the tumor while sparing healthy surrounding tissue. The treatment’s
success rate is equal or better than that of prostate surgery, and it is often chosen as an
alternative to surgery and other forms of radiation.
Proton beam therapy has been around since the early 1950s and has been used in a
hospital setting since 1990. As the treatment continues to gain popularity and prevalence,
more and more proton therapy centers are opening throughout the country. The world’s
first hospital-based proton therapy center is located at Loma Linda University Medical
Center in Southern California. Other U.S. center locations include: Massachusetts
General Hospital in Boston; the Midwest Proton Radiotherapy Institute in Bloomington,
Ind.; the University of Florida Shands hospital in Jacksonville, Fla.; and the M.D.
Anderson Proton Therapy Center in Houston.
Proton Beam Therapy versus Surgery
Is surgery more cost-effective? It may seem to be, but it is important take into account the
total cost of a surgical procedure, which goes beyond the surgery and hospital stay.
When you factor in the cost of intensive post-operative treatment, home medical
equipment and supplies, multiple physician’s visits, the risk of infection and
complications, potential costs of impotence treatment, and the emotional impact, the cost
of surgery will likely eclipse the cost of proton treatment.
Why You May Be Denied Insurance Coverage:
Proton beam therapy is gaining wider acceptance as a practical choice for men diagnosed
with prostate cancer. However, some members of the medical community have been slow
to recognize the benefits of the treatment.
Getting provider approval depends in large part on the patient’s type of health insurance,
age and state of residence. Preferred Provider Organizations (PPOs) are more likely to
cover proton beam therapy than Health Maintenance Organizations (HMOs). Some states
have better appeal procedures than others. Most states have independent review boards
that have the power to overrule an insurance company’s denial.
Increase Your Chances for Coverage
Just as you did extensive research on your disease and the treatment options available to
you, you need to devote the same amount of time and energy to understanding your
health insurance plan. Doing this before you begin treatment will help avoid unpleasant
surprises once you’ve begun or completed treatment. Here are proactive steps to take to
help ensure coverage:
• Obtain an updated, complete copy of your health plan (sometimes known as the
Summary Plan Description).
• Ask questions. Talk with your employer’s health benefits department. Call your health
plan’s customer service line. Ask about any policies not included in the benefit book,
such as appeal processes and how denials are formulated. Explore what legal health
insurance requirements your state mandates.
• Get a letter of referral from your physician that clearly indicates that he or she strongly
recommends proton beam therapy. Also, obtain a “letter of medical necessity” from your
urologist.
• Find out the names of other patients who were covered by your provider for this
procedure in the past. This will substantially strengthen your case if your coverage is
denied.
• If coverage is an issue with your HMO, consider switching to a PPO plan with the same
provider. The best time to make the change is during “open season” or at policy renewal
time.
• Shop around for other insurance companies and switch to a provider that is known for
approving proton beam therapy. However, be careful not to cancel your original coverage
until the new coverage takes effect.
Getting Authorized
The pre-certification process is the first step to getting a treatment authorized. This
usually begins with a call to the health plan’s pre-certification or pre-approval
department. This can be done either by the patient, a patient’s representative, the
patient’s health care provider or the hospital.
A nurse at the health plan will review the medical and clinical information pertaining to
the case to make sure it meets established guidelines. If it does, the nurse will authorize
the request and the health plan will cover the service.
If the service does not meet guidelines, the case is referred to the health plan’s physician
reviewer (usually the medical director), who will decide whether to approve or deny the
request. The case may also be put on “pend” status, which means that additional
information is needed — usually from the patient’s physician.
Denied? Steps to a Successful Appeal
You will receive a letter if your request is denied or pended. Health plans are required to
state the exact reasons for the denial and provide an opportunity to discuss the denial with
the reviewer.
Whenever you communicate with the insurance company, it’s important to take careful
notes. Document every phone call you make, as well as those made to you. Note the date
and time, and be certain to get the name and position of anyone you talk to. Keep copies
of all written communication that you send to the insurance company, hospitals and
doctors. Save copies of anything sent to you.
If your coverage is denied, follow these steps to appeal your case:
1. Ask the health plan what guidelines they used to formulate the denial.
2. Submit documentation clearly stating the reason for the requested service. Health plans
make their coverage decisions based on the documentation you provide, so it’s in your
best interest to provide complete information up-front. Print out any information that
supports your position. Keep copies of all medical documentation. In many cases, your
physician can provide the medical documentation you need. Your physician can also
discuss the denial with the health plan’s physician reviewer.
3. Follow up with the health plan if it hasn’t responded in a timely manner.
4. If your appeal is not overturned on the first try, request a second appeal. Most plans
also provide a third level of appeal. If all levels of appeal are overturned, consider filing
with an independent review board or the insurance commissioner. At this point, you may
require a lawyer. Be persistent, factual and adhere to all requests and requirements of the
health plan.
Do not bypass any step in the appeal process. If your first-level appeal is denied, do not
jump right to an independent reviewer. Some insurance regulations and even some
independent review boards require the policyholder to first file an internal appeal with the
insurance carrier. This is a prerequisite to getting an outside agency or, in some cases,
winning in court.
Points and Counterpoints
Knowing the common reasons for why proton beam therapy coverage is denied can help
you make a stronger case for approval. Here are a few of the reasons that an insurance
company might cite for denying a claim and what you can counter with to strengthen
your argument:
1. Proton beam therapy is experimental (or investigational):
Proton beam therapy is neither experimental nor investigational. It is an established form
of treatment that is widely accepted by physicians, government agencies and many
insurers, including Medicare and Medicaid (which do not cover investigational or
experimental treatments).
2. Proton beam therapy is not medically necessary:
The definition of “medically necessary” is broad. The Code of Federal Regulations
defines “medically or psychologically necessary” in part as follows: “The frequency,
extent, and types of medical services or supplies which represent appropriate medical
care and that are generally accepted by qualified professionals to be reasonable and
adequate for the diagnosis and treatment of illness…”
It will be beneficial for you to obtain a “letter of medical necessity” for proton beam
therapy from your doctor.
3. Proton beam therapy is outside the plan’s medical network:
This may be the toughest type of claim to refute. One way is to show the benefits of
proton beam therapy and note that there are no proton beam therapy facilities within the
network.
4. Other treatment methods have the same effectiveness as proton beam therapy:
Point out that proton beam therapy is noninvasive and has fewer side effects than other
treatments.
After a Successful Appeal
Once you have received approval for your treatment, make sure that the costs are covered
at the rate described in your plan. If you find that is not the case, you will need to appeal
that as well.
Keep a copy of your approval letter. While this information should exist in the health
plan’s computer system, you can avoid unnecessary delays by having a copy of the
approval letter ready to provide upon request.
Helpful Web Sites:
(Link to list here)
Insurance Plans That Have Approved PBT in the Past
(Link to list here)