SHELBY LIVINGSTON April 29, 2019
At least
two lawsuits have been filed against UnitedHealthcare in the last two months
alleging the insurance company improperly denied patients coverage for a
certain type of cancer treatment that insurers have long been reluctant to pay
for.
On
Monday, U.S. District Judge Robert Scola recused himself from deciding one of
the lawsuits filed this month in Miami because of personal experience with the
cancer treatment, writing in an order of recusal that denying a patient the
treatment "is immoral and barbaric."
"It
is undisputed among legitimate medical experts that proton radiation therapy is
not experimental and causes much less collateral damage than traditional
radiation," Scola wrote. "To deny a patient this treatment, if it is
available, is immoral and barbaric."
The
treatment, called proton beam therapy, is a radiation therapy used by
oncologists to kill cancerous tumors. Compared with traditional radiation,
proton therapy is used to target a specific site on the body, limiting damage
to surrounding tissues.
According
to the complaints, UnitedHealthcare denied coverage for the proton beam therapy
for one patient's prostate cancer and another patient's cervical cancer, in
both instances determining that the treatment is experimental and unproven. But
the patients, who are seeking class action status for their lawsuits, argue
that proton therapy is a decades-old effective and established cancer
treatment. It was approved by the Food and Drug Administration in 1988 and is
paid for by Medicare, according to the complaints.
"Instead
of acting solely in the interests of the participants and beneficiaries of its
health insurance plans, upon information and belief, UHC denied coverage for
PBRT to treat prostate cancer because, on average, PBRT is significantly more
expensive than traditional Intensity Modulated Radiotherapy or other
treatments," one complaint alleged.
UnitedHealthcare
said Monday that it "bases its medical policies and coverage
decisions—including for proton beam therapy—on the prevailing published
clinical and scientific evidence."
UnitedHealth
isn't the only insurer that has denied coverage of proton beam therapy for
certain cancers. Last year, an Oklahoma jury told Aetna to pay $25.5 million to a patient's estate after the
insurer denied to pay for the treatment based on grounds that it was
experimental. Other insurers and policy experts have warned in recent years that there's a lack of evidence
showing proton therapy produces better outcomes than other types of radiation.
Despite that, hospitals and other companies have rushed to build expensive proton-beam therapy centers.
Richard
Cole, the plaintiff in the amended complaint filed last week in a federal
district court in Miami, was diagnosed with prostate cancer in April 2018 and
his physicians at Baptist Health South Florida recommended proton therapy as an
alternative to another type of radiation called intensity modulated radiation
therapy, or IMRT, because of the likelihood of a better health outcome,
according to the complaint.
UnitedHealthcare,
which administered medical benefits on behalf of Cole's self-funded employer,
denied his prior authorization request and subsequent appeals for coverage of
proton therapy on the grounds that it fell under an exclusion for experimental,
investigational or unproven services for patients over 19 years old. Cole paid
for the treatment out of pocket.
UnitedHealthcare
then changed its policy effective Jan. 1, 2019, to cover proton beam therapy
for prostate cancer, acknowledging that proton therapy and IMRT are
"proven and considered clinically equivalent for treating prostate
cancer," the complaint stated. Still, UnitedHealthcare's independent
reviewer continued to deny Cole coverage of the treatment as recently as
February 2019.
In the
other case filed in March, patient Kate Weissmann, whose employer contracted
with UnitedHeathcare for benefits administration, similarly alleged that the
insurer repeatedly denied coverage for proton therapy to treat her cervical
cancer in 2016 based on a policy that relied on "outdated medical
evidence, ignores contemporary medical evidence, and relies more heavily on
actuarial calculation of risk pools" because it covers the therapy for
patients younger than 19 and older than 65.
She also
alleged that UnitedHealthcare relies on an "inadequate review of clinical
records" by medical directors who are unqualified to make coverage
determinations.
The
insurer denied coverage despite recommendations by her physicians at Mass
General and the Dana-Farber Cancer Institute that proton therapy was essential
for Weissman's treatment for reasons including IMRT put her at risk for bowel
and gastrointestinal toxicity while proton therapy reduced that risk. Weissman
shelled out $95,000 out of pocket for proton therapy.
The
complaints do not state how many patients might be affected by
UnitedHealthcare's coverage policy for proton beam therapy. However, the
lawsuit filed in Miami noted that 5,000 patients within prostate cancer were
treated using proton therapy nationwide in 2018.
Judge
Scola wrote in his recusal order that UnitedHealthcare denied coverage of
proton radiation treatment requested by his close friend in 2015.
UnitedHealthcare agreed to pay for the $150,000 treatment when threatened with
litigation. The judge also wrote that he personally was diagnosed with prostate
cancer in 2017 and the experts he consulted throughout the country determined
that proton therapy was the "wiser course of action" if he opted for
radiation.
https://www.modernhealthcare.com/insurance/judge-recuses-himself-unitedhealthcare-proton-therapy-lawsuits
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