“What has always been so stunning to me is that statistically only 1.5% of all radiation-related claims made in the U.S. healthcare system annually are for proton therapy. So it is truly a wonder why insurers take such hardline positions relating to PT especially when the science so clearly establishes PT's superiority for many cancer diagnoses over other traditional forms of radiation," Timothy J. Rozelle, associate attorney for Kantor & Kantor, told HCB News in 2021.

Molloy v. Aetna
Paul Molloy and his wife, Jacqueline filed their suit against Aetna in the U.S. District Court for the Eastern District of Pennsylvania in 2020 after it refused to cover proton therapy to treat his brain tumor. The insurer described the treatment as "experimental and investigational" and not medically necessary.
According to the case, Aetna refused to cover the treatment for 142 patients between June 2017 and October 2020. Aetna filed a motion to dismiss the case in 2019. But Judge Cynthia M. Rufe has not made a decision on that request yet, nor on the settlement agreement.

Shortly after the suit was filed, the health insurer expanded the number of conditions for which proton therapy was covered, according to Bloomberg Law.

The health insurer lost a similar case in 2022 against a non-metastatic breast cancer patient and a prostate cancer patient. Aetna argued that proton therapy did not meet its definition of "medically necessary," but failed to justify how it did not, according to the judge.

Collins says that the current Aetna case, unlike other lawsuits, was not litigated long, with no depositions or expert witness testimonies. "I believe Aetna recognized that it is time for insurers to move on from the unduly restrictive proton therapy utilization guidelines that invite wrongful denials and consequential litigation, and to instead focus on a favorable financial solution," he said.

As part of the settlement, both Paul and Jacqueling will receive an additional $25,000 each.

Affordable access in the future
Several initiatives underway are also expected to propel insurers to expand coverage. President Joe Biden's Cancer Moonshot initiative, for example, aims to reduce the cancer death rate by half within 25 years by accelerating cancer research and fostering greater collaboration. As a result, scientists will be able to add new findings to the growing amount of evidence that further supports the use of proton therapy.

This, along with more successful litigation, will make it more challenging and financially draining from legal expenses for insurers to continue to deny coverage and force them to reevaluate and expand their policy guidelines, says Collins.

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