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LisaA

Proton radiation therapy not covered by insurance

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My radiation oncologist wants to use Proton Radiation Therapy to treat the tumor. The proton radiation facility called me today and said that my insurance (Aetna) does not cover this treatment and if I were to have it done it would cost me out of pocket $10,000.  They would submit to Aetna after that time, but said that they typically do not cover it.

Is this what others have experienced? Have others just paid the out of pocket? It does seem like it would be the better method of radiation application. Does anyone have any input?

Thank you

 

 

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For what it's worth, here's what Aetna says about Proton Radiation Therapy: http://www.aetna.com/cpb/medical/data/200_299/0270.html.

It's pretty long, I didn't read the whole thing, but it appears to boil down to their conclusion that there's insufficient evidence that it's more effective than more conventional radiation for lung cancer.  It IS approved for some other cancers.

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That sucks, LexieCat…. I wonder what people do? Just pay the huge out of pocket for enhanced treatment or have the regular radiation done that also affects healthy tissue?

 

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Well, my understanding is that the other precision radiation is pretty precise--IOW, there should be relatively little impact on the surrounding tissues.  The proton therapy seems to be mainly used where it would be particularly dangerous to surrounding tissues.  

 

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I just found this: https://www.proton-therapy.org/patient-resources/insurance/.

No idea how legit the information is, nor, of course, am I in a position to know what the best treatment for YOU might be, but figured I'd pass it along in the event you want to pursue it.

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Hi Lisa, 

Insurance!  Total nightmare!  Aetna just had a $25 million settlement for denying radiation treatment that they deemed experimental in Oklahoma this year.  I would have your doctor file a prior authorization request outlining the medical rationale for this treatment.  If the prior authorization request is denied, then an appeal can be filed (and should be).  The final level of appeal is an Independent Review Organization (IRO).  The insurance companies lose the majority of IRO appeals.   

I think Aetna might be a little gun shy about denying treatment to cancer patients as the jury award was intended to send a very strong message.   

See if you can find out if your employer is self insured.  If so, your employer may elect to instruct Aetna to pay the claim on an "extra-contractual agreement". 

If all else fails, the hospital has a financial team that will be able to assist you.  Please do not make any out of pocket expenditures until you have exhausted the appeals process and employer extra-contractual agreements.   

These requests are reviewed very quickly-usually within a matter of "a few days".   Ugh.  

The insurance process is really terrible (my Foundation One claim has now been denied three times!! IRO here we come.... 🙁

Michelle 

Edited by Rower Michelle
number correction

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Lisa,

I've been to several symposiums on precision radiation and proton beam therapy.  Understand that precision radiation uses ionizing radiation (gamma rays) that are narrowly focused.  Proton Beam Therapy uses non ionizing accelerated protons that are narrowly focused.  Both kill tumors.  There are two significant differences: cost and the amount of tissue surrounding the tumor that is damaged.  Proton beam therapy is very, very precise.  It is often used in very young children as a way to minimize as much collateral tissue damage as possible.  But, proton therapy is extremely expensive and precision radiation can often accomplish the same result at much reduced cost.

I'd ask your radiation oncologist why proton beam therapy and would precision radiation like CyberKnife, for example, accomplish the same objective.  If the oncologist really believes proton beam is necessary, he or she has to provide a lot of ammunition to battle insurance.  

Stay the course.

Tom

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On ‎1‎/‎30‎/‎2019 at 7:27 PM, LexieCat said:

I just found this: https://www.proton-therapy.org/patient-resources/insurance/.

No idea how legit the information is, nor, of course, am I in a position to know what the best treatment for YOU might be, but figured I'd pass it along in the event you want to pursue it.

Thank you Lexie. As a result of your informative link, I did contact our employer plan administrator today to see if they could do something to get this approved. Thanks for the great info!

 

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