Obtaining Health Insurance Coverage for Proton Treatment

Receiving a cancer diagnosis is difficult and can be very frightening. Learning your health insurance provider has denied coverage for the treatment plan you and your physician have determined is most appropriate can make things evern harder. Fortunately, the majority of proton therapy centers have assembled teams of experts trained specifically to help patients appeal insurance denials. You, the patient, can also help.

Note that thousands of men diagnosed with prostate cancer have successfully appealed their health insurance plan’s denial for coverage. There's a good chance that you can too. Fighting and winning an appeal takes patience, persistence, and a good understanding of why proton therapy is the best treatment option for you.

This guide - provided by the National Association for Proton Therapy - provides tips and strategies to help you strengthen your case.

Insured Through Your Employer? 

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.

Denied Coverage and Looking for an Attorney? 

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 nearly 40 proton facilities in the U.S. 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 30 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.

Help Gather Paperwork to File Your 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.

The BOB's Insurance Appeals Strategy Document

In the past, we directed all prospective proton patients with insurance issues to our Insurance Appeals Strategy Document (ASD). This 80-page document is full of information about different types of denial reasons and how to handle them. It also contains sample appeal letters, written by BOB members, that have helped to overturn denials.

In the past, we also recommended patients draft their own appeal letters, include personal health information (health history – anything that may relate to proton therapy being a superior treatment option versus the other, more invasive procedures), a physician’s note, and back-up research (all included at the end of the ASD). Compiling a comprehensive appeal based on the denial reason was successful much of the time, however things have changed.

We still recommend including the information mentioned above in an appeal, but these days the proton centers are involved heavily in the appeals process. In fact, most of them have dedicated teams of experts to lead the appeals process on behalf of patients. 

So, in addition to reviewing the ASD, we encourage patients to contact the proton center and request to speak with an insurance specialist.

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.