Standard Process for Obtaining Insurance Coverage for Proton Treatment:
The facility that will provide your treatment applies to the insurer for approval. If the insurer covers proton, then you are good to go. If they deny, then you can appeal based on the denial reason. It's beneficial to have the facility file for initial approval as the insurer needs specific information including medical treatment and diagnosis codes to make their determination.
Insured Through Your Empoyer?
Find out if the plan is self-funded. In that case, the employer pays the insurer to administer the plan and the employer can tell the insurer to cover something normally denied. Then set up an appointment with your human resources department and explain your situation, focusing on how the employer will benefit from your proton therapy treatment (i.e. If you are not traveling for treatment, there will less or no down time at work; no lost productivity; little or no cost in future medical claims for side-effect treatments, etc.). Ask your employer if they will intervene for you. Provide them with articles, surveys and information about proton therapy and a copy of Bob Marckini's book, "You Can Beat Prostate Cancer: And You Don't Need Surgery To Do It" if they are willing to learn more.
If you find that the plan is self-funded and you have further troubles, contact DHickey@protonbob.com and we can help you formulate the best way to approach your employer.
Make sure to get the denial in writing and the reason for the denial. If the insurer claims that proton is experimental and using that as the denial reason, it is the easiest denial to appeal (Note: As of this print date, Medicare covers proton therapy for prostate cancer at 80 percent of the usual and prevailing fee, and Medicare never covers anything experimental). Note also that there are multiple proton facilities in the US and worldwide providing this proton treatment with many more in the planning stage. Proton therapy has been used to treat prostate cancer with excellent results for 25 years.
Most insurers previously have covered proton, however many are now denying coverage for reasons other than it being experimental. They claim it is medically unnecessary because of other available, less costly, treatments. Learn the truth about cost for proton therapy here.
File Your Own Appeal
If you are denied coverage for proton therapy, we encourage you to research, develop, and file information for your appeal. While the facility and/or physician may offer to submit your appeal for you, they seldom have the time or manpower to do the extensive, thorough and personal appeal that has a better change of succeeding. Our Insurance Appeals Strategy Document (more info on this below) will provide a roadmap to develop your appeal, and we are here to offer additional guidance as needed. Keep in mind that you have only a few appeal levels (typically 3) of appeal, so each one needs to count. Follow the appeal process that is outlined in your insurance handbook.
Our Insurance Appeals Strategy Document (ASD) contains a wealth of information on how to deal with your insurer, how to appeal various denials, and includes sample letters that were crafted by BOB members and used to help successfully overturn denials.
Note: You will find the Medicare coverage statement in the ASD. Be sure to include it in your appeal.
Note: While you will need to provide the proof that proton for prostate cancer is not experimental, the insurer must also prove to you that it is. This means you have the right to access the documentation they use to support that claim. More than likely, anything they provide will be outdated by years.
Are you a veteran with any ground time in Vietnam?
Contact DHickey@protonbob.com and let us know.