Why Do Insurance Companies Deny Proton Therapy?

Insurance companies deny proton therapy in some cases, often claiming that it’s an elective procedure that’s unnecessary or is simply experimental. This decision can significantly impact patients who need this therapy to help treat cancer. 

Female patient entering a scan machine while technician standing and looking at her.

If an insurance company denies coverage for proton therapy when you need it most, you may be able to fight for these benefits with the help of an attorney.

What Is Proton Therapy?

Also known as proton beam therapy, proton therapy is a specific type of radiation treatment for cancer. It works similarly to x-rays by treating cancer using external beams, only it uses protons for beams, unlike x-rays. It first developed in the early 20th century until eventually, in 1988, the U.S. Food and Drug Administration (FDA) approved it as an appropriate treatment for cancer. Medical professionals may recommend using this treatment as a standalone treatment, or they may use it to complement other procedures, such as x-rays, chemotherapy, and surgery.

Proton therapy works by using a cyclotron or synchrotron that accelerates positively charged protons. The energy this process generates makes the protons viable for treating different types of cancer by directly destroying cancer cells. The proton therapy equipment then delivers the radiation into the patient’s body at a great enough depth to effectively treat the target area. At the same time, the radiation doesn’t affect the surrounding healthy skin and organs. 

Ultimately, proton therapy’s less invasive technique makes it a radiation treatment that’s considerably safer than others. As such, it’s popular among doctors and patients alike.

Some potential cancers this therapy can treat include:

  • Lung cancer
  • Breast cancer
  • Brain tumors
  • Spinal tumors
  • Tumors in the head and neck
  • Eye cancer

Does Insurance Cover Proton Therapy?

Some insurance policies cover proton therapy. Despite the long history of proton therapy and proven results, many insurance companies still deny coverage due to the belief that it’s either medically unnecessary or experimental in nature. Because of proton therapy’s validity as a cancer treatment that can save people’s lives, it may count as insurance bad faith if a company denies coverage for this treatment. 

Why Insurance Companies Deny Proton Therapy

Insurance companies may deny proton therapy for a couple of reasons.

The first reason for denial could be due to the insurance company’s labeling of the procedure as either “investigational” or “experimental.” In these instances, insurers may argue that the procedure doesn’t have enough proof of results to make it a procedure worth covering. 

The second could be due to an insurer’s belief that the procedure isn’t medically necessary. This means that the insurer believes alternative treatments could achieve the same or similar results. The underlying reason for denial is often because proton therapy is somewhat more expensive than other types of cancer treatments, making insurers less inclined to cover it when cheaper alternatives are available.

While insurers may still choose to deny coverage for proton therapy, it’s a treatment that many people need, which is why doctors recommend it. It’s safer than other radiation treatments, and it can get results in many cases, although it’s not an effective treatment for all cancers. If an insurance company denies proton therapy, cancer patients may be able to fight this decision.

How to Fight an Insurance Denial

When an insurance company refuses to cover proton therapy, you may have the option of appealing this decision. With the help of an insurance fraud lawyer, you may be able to build a strong case and successfully navigate the appeals process. 

The following are some of the steps that you can take to appeal a denial and get the coverage you need for proton therapy.

What You Need to Know Before Appealing a Denial

Prior to beginning the appeals process, you should get a better understanding of your insurance policy and what it will take to appeal the insurer’s decision.

For example, you should learn about the specific type of health insurance plan you use, whether it’s a Medicare plan, Preferred Provider Organization (PPO), or another type of plan. Additionally, confirm the specific reason why the insurance company denied coverage for proton therapy, which should be included in a notification of denial. You should also find out what you’ll need to do to appeal the insurer’s decision, based on the insurer’s unique process. 

For assistance with this, you may be able to consult the handbook that your insurance company provides you. You may also conduct research online if this information isn’t available elsewhere. 

Get a “Letter of Medical Necessity” If Possible

With a deeper understanding of your options, coverage, and the appeals process, you can begin seeking help from physicians who recommend or provide proton therapy.

If your insurer denies coverage because the company considers it a medically unnecessary procedure, you may be able to get a physician to back your decision to receive this treatment. Ask your doctor for a “Letter of Medical Necessity” that discusses this procedure in depth and helps convince insurers that it’s a medically necessary treatment. This literature will clarify why your doctor recommended this procedure in place of or in addition to others, including x-rays and other potentially more risky procedures.

Consider Hiring an Attorney

Many individuals who want to appeal a proton therapy denial may not know how to approach the process, increasing the risk of making a critical mistake along the way. When you wish to appeal an insurer’s decision, there’s a set process in place with specific steps that you must follow. If you fail to follow these steps and take the correct course of action, you will ultimately be unable to successfully appeal, which can prolong the delay of treatment.

For some help going through the appeals process, consider working with an insurance fraud attorney who has experience handling these cases. The right attorney can help guide you through the appeals process, so you can seek the treatment you need.

Gather Documentation to Support Your Appeal

Before you officially begin the appeals process, you should collect all pertinent documentation to provide you with additional support. 

Documentation in an insurance appeal could include items such as:

  • Records of communication with physicians and healthcare providers, including recommendations for proton therapy and the reason for these recommendations
  • Records of previous treatments, health complications, and appointments with physicians
  • Records of communication with the insurance company, including email correspondence and phone conversations

All of this documentation may go a long way in helping prove the necessity of proton therapy and reverse the insurer’s decision to deny coverage.

Submit Your Appeal with a Formal Letter

The final step when you’re ready to begin the appeals process is to craft a letter and send it to your insurer. Your appeal letter should include all necessary information that goes toward proving that you require this procedure and that it will likely benefit you. You should address this letter to someone in the insurer’s appeals department, which you can identify when researching the appeals process. Also, keep in mind that you must write this letter and send it through the mail—email and other delivery forms are invalid and won’t initiate the appeals process.

In your appeal letter, you’ll need to provide insurers with a variety of details that support your appeal. For instance, you will need to include the physician’s reason for recommending this procedure. What is it about this particular procedure that makes it ideal for treating your specific type of cancer?

When it comes to reasoning that the cost of the procedure is worth the coverage, list the potential costs of another procedure that could require even more coverage. For example, chemotherapy could come with many side effects that make patients’ lives difficult, including physical and psychological symptoms that require separate treatment.

In addition, include information about your medical history, which could further show that you’re in need of proton therapy. You may have received previous treatments that weren’t as effective as you’d hoped, or you may have certain conditions that proton therapy has proved to be highly effective at treating.

After sending this letter, you’ll need to wait for the insurer to review your appeal. Insurance companies tend to respond in around 30 to 60 days. 

When Insurance Companies Deny Proton Therapy

Although proton therapy is a treatment that has been around for many years and continues to help treat a variety of cancers, insurance companies may choose to deny coverage for this treatment. If an insurance company denies this treatment, it can have a significant effect on cancer patients’ health and emotional well-being. Insurance companies may deny this treatment and claim that it’s either investigational or simply not necessary, but you may have the chance to overturn this decision with an effective appeal.

With the help of physicians and legal representation, you may have the chance to successfully appeal insurance denials, including denials for proton therapy and other critical treatments. Doing so can increase your chances of getting the care you need as soon as you need it.

Chicago personal injury and workers’ compensation attorney Howard Ankin has a passion for justice and a relentless commitment to defending injured victims throughout the Chicagoland area. With decades of experience achieving justice on behalf of the people of Chicago, Howard has earned a reputation as a proven leader in and out of the courtroom. Respected by peers and clients alike, Howard’s multifaceted approach to the law and empathetic nature have secured him a spot as an influential figure in the Illinois legal system.

Years of Experience: More than 30 years
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Bar & Court Admissions: Illinois State Bar Association, U.S. District Court, Northern District of Illinois, U.S. District Court, Central District of Illinois
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