From the March 2022 issue of HealthCare Business News magazine
HCB News (www.dotmed.com/news) is a leading news source for proton therapy current events. In this section we recap some of the highest-impact stories we’ve published over the last six months.
For more stories like these, visit our news site and click “Proton Therapy” in the red navigation bar at the top of the screen. Registering for our online news is completely free.
Court finds Aetna wrong for refusing proton therapy coverage
A federal judge ruled in February that Aetna wrongfully denied patients access to proton therapy.
An advanced form of radiation therapy, proton therapy is designed to better target and eradicate tumors with less risk of damaging healthy tissue and creating short-term and long-term side effects in patients.
The insurer, which argued that the treatment was experimental and investigational, failed to justify how proton therapy did not align with its definition of what is “medically necessary,” according to Judge Kenneth Marra of the U.S. District Court for the Southern District of Florida on Thursday.
Marra ruled partially in favor of plaintiffs Sharon Prolow and Mark Lemmerman, who both sought coverage for proton beam radiation therapy for non-metastatic breast and prostate cancer, respectively, according to Modern Healthcare.
"Given the extensive medical literature, detailed medical records, treatment plans and compelling evidence of individual risk factors supplied by Ms. Prolow's and Mr. Lemmerman's treating physicians, the court concludes that the recommendations of the plaintiffs' physicians reflected prudent clinical judgment," said Marra in his ruling.
He did, however, say it was unnecessary to take up the claim that Aetna violated the Employee Retirement Income Security Act by denying coverage. ERISA refers to a set of federal laws that are part of the Employee Retirement Income Security Act of 1974. Under this Act, employers pay employer-based plans to create clinical guidelines for judging and approving claims such as PT. Many insurance providers often use these guidelines as grounds for its approvals and denials, and all claims and appeals processes must be exhausted before a civil lawsuit can be filed.
Prolow had filed the suit on behalf of beneficiaries of ERISA plans and claimed that Aetna violated its fiduciary obligations when it denied coverage for proton beam radiation therapy for breast cancer.
Is proton CT superior to conventional CT for planning proton therapy?
Proton therapy manufacturer ProtonVDA and researchers at Loyola University Stritch School of Medicine, Northern Illinois University and Loma Linda University published findings in January determining proton CT reduced range uncertainties, which could allow radiation oncologists to potentially use smaller margins around tumors and more precisely deliver proton radiation to cancer sites.
