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Does Aetna's $3.4 million proton therapy settlement signal a shift in coverage?

by John R. Fischer, Senior Reporter | March 20, 2023
Insurance Rad Oncology Proton Therapy
Aetna has settled a $3.4 million lawsuit over its refusal to cover proton therapy for 142 patients.
Accused of wrongfully denying coverage for proton therapy, Aetna Life Insurance Co. has agreed to pay a settlement of $3.4 million to 142 cancer patients collectively in the suit, Molloy v. Aetna.

Patients who were denied coverage but could not or chose not pay out-of-pocket are entitled to at least $10,000. Those denied who paid out-of-pocket can receive up to $24,000 with proof of their expenses. Separately, patients can seek up to $1.5 million to cover counsel fees and expenses, according to reported Bloomberg Law.

Rich Collins, a partner at Arnall Golden Gregory with 25 years in healthcare litigation, told HCB News that these cases are the “catalyst for change” that are making insurers reconsider their stance on proton therapy.

“I have seen over the past five years since we started litigating these cases that a number of insurers have revised their guidelines to allow for greater utilization of proton therapy for more types of cancer diagnoses. I view each revision as the insurers’ incremental concession of their losing basis for denying coverage,” he said.

Numerous studies have illustrated proton therapy's efficacy in treating various cancers. The treatment is generally covered by Medicare, according to Mayo Clinic, and universally covered by commercial insurers for children.

But for years, commercial insurers have limited coverage for adults to only a small number of indications, saying the treatment's results are comparable to that of conventional radiotherapy in some cases and calling it "experimental and investigational" and not "medically necessary." It also costs at least twice as much as the latter, say experts in the field.

In the last few years, several payers — UnitedHealthcare, Humana Insurance Co., Blue Shield of California, Blue Cross Blue Shield of North Carolina — have been hit with lawsuits for their denials. Many have been successful, putting more pressure on them to expand coverage guidelines.

Numerous studies have illustrated that proton therapy, which precisely targets cancerous lesions and causes less damage to nearby tissue than conventional radiotherapy, yields superior results for many indications. The treatment is generally covered by Medicare, according to Mayo Clinic, and universally covered by commercial insurers for children.

But for years, commercial insurers have limited coverage for adults to only a small number of indications, saying its results in certain cases are comparable to radiotherapy and calling it "experimental and investigational" and not "medically necessary." Studies also show that the price is at least twice that of radiotherapy.

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