Medicare Update!

Medicare Payment & Coverage for Proton Beam Radiation Therapy: Winter 2010/2011 Update


You’ve been diagnosed with prostate cancer and decided that proton beam therapy is the best treatment choice for you. The problem is, your health insurance provider has denied coverage for the therapy. What do you do next?

Hundreds of men have successfully appealed their insurance companies’ denials for proton beam therapy coverage, and there is a good chance that you will be able to do it, too. Winning an appeal takes patience, persistence and a good understanding of why proton beam therapy is a viable treatment option. This guide provides various tips and strategies to help you strengthen your case.

* Read Wall Street Journal article on how to fight insurance coverage denials

About Proton Beam Therapy

Proton beam therapy is a precise, noninvasive treatment that targets cancer with minimal side effects. By shaping a beam to match the specific shape of a tumor, physicians can precisely target the tumor while sparing healthy surrounding tissue. The treatment’s success rate is equal or better than that of prostate surgery, and it is often chosen as an alternative to surgery and other forms of radiation.

Proton beam therapy has been around since the early 1950s and has been used in a hospital setting since 1990. As the treatment continues to gain popularity and prevalence, more and more proton therapy centers are opening throughout the country. The world’s first hospital-based proton therapy center is located at Loma Linda University Medical Center in Southern California. Other U.S. center locations include: Massachusetts General Hospital in Boston; the Midwest Proton Radiotherapy Institute in Bloomington, Ind.; the University of Florida Shands hospital in Jacksonville, Fla.; and the M.D. Anderson Proton Therapy Center in Houston.

Proton Beam Therapy versus Surgery

Is surgery more cost-effective? It may seem to be, but it is important take into account the total cost of a surgical procedure, which goes beyond the surgery and hospital stay.

When you factor in the cost of intensive post-operative treatment, home medical equipment and supplies, multiple physician’s visits, the risk of infection and complications, potential costs of impotence treatment, and the emotional impact, the cost of surgery will likely eclipse the cost of proton treatment. 

Why You May Be Denied Insurance Coverage

Proton beam therapy is gaining wider acceptance as a practical choice for men diagnosed with prostate cancer. However, some members of the medical community have been slow to recognize the benefits of the treatment.

Getting provider approval depends in large part on the patient’s type of health insurance, age and state of residence. Preferred Provider Organizations (PPOs) are more likely to cover proton beam therapy than Health Maintenance Organizations (HMOs). Some states have better appeal procedures than others.  Most states have independent review boards that have the power to overrule an insurance company’s denial.

Increase Your Chances for Coverage

Just as you did extensive research on your disease and the treatment options available to you, you need to devote the same amount of time and energy to understanding your health insurance plan.  Doing this before you begin treatment will help avoid unpleasant surprises once you’ve begun or completed treatment. Here are proactive steps to take to help ensure coverage:

Getting Authorized

The pre-certification process is the first step to getting a treatment authorized. This usually begins with a call to the health plan’s pre-certification or pre-approval department.  This can be done either by the patient, a patient’s representative, the patient’s health care provider or the hospital. 

A nurse at the health plan will review the medical and clinical information pertaining to the case to make sure it meets established guidelines. If it does, the nurse will authorize the request and the health plan will cover the service. 

If the service does not meet guidelines, the case is referred to the health plan’s physician reviewer (usually the medical director), who will decide whether to approve or deny the request.  The case may also be put on “pend” status, which means that additional information is needed — usually from the patient’s physician.

Denied? Steps to a Successful Appeal

You will receive a letter if your request is denied or pended.  Health plans are required to state the exact reasons for the denial and provide an opportunity to discuss the denial with the reviewer.

Whenever you communicate with the insurance company, it’s important to take careful notes. Document every phone call you make, as well as those made to you.  Note the date and time, and be certain to get the name and position of anyone you talk to. Keep copies of all written communication that you send to the insurance company, hospitals and doctors. Save copies of anything sent to you.

If your coverage is denied, follow these steps to appeal your case:

  1. Ask the health plan what guidelines they used to formulate the denial. 

  2. Submit documentation clearly stating the reason for the requested service. Health plans make their coverage decisions based on the documentation you provide, so it’s in your best interest to provide complete information up-front. Print out any information that supports your position.  Keep copies of all medical documentation. In many cases, your physician can provide the medical documentation you need.  Your physician can also discuss the denial with the health plan’s physician reviewer.

  3. Follow up with the health plan if it hasn’t responded in a timely manner.

  4. If your appeal is not overturned on the first try, request a second appeal.  Most plans also provide a third level of appeal.  If all levels of appeal are overturned, consider filing with an independent review board or the insurance commissioner.  At this point, you may require a lawyer. Be persistent, factual and adhere to all requests and requirements of the health plan.

Do not bypass any step in the appeal process.  If your first-level appeal is denied, do not jump right to an independent reviewer.  Some insurance regulations and even some independent review boards require the policyholder to first file an internal appeal with the insurance carrier.  This is a prerequisite to getting an outside agency or, in some cases, winning in court.

Points and Counterpoints

Knowing the common reasons for why proton beam therapy coverage is denied can help you make a stronger case for approval. Here are a few of the reasons that an insurance company might cite for denying a claim and what you can counter with to strengthen your argument:

  1. Proton beam therapy is experimental (or investigational):

    Proton beam therapy is neither experimental nor investigational. It is an established form of treatment that is widely accepted by physicians, government agencies and many insurers, including Medicare and Medicaid (which do not cover investigational or experimental treatments).

  2. Proton beam therapy is not medically necessary:

    The definition of “medically necessary” is broad.  The Code of Federal Regulations defines “medically or psychologically necessary” in part as follows: “The frequency, extent, and types of medical services or supplies which represent appropriate medical care and that are generally accepted by qualified professionals to be reasonable and adequate for the diagnosis and treatment of illness…”

    It will be beneficial for you to obtain a “letter of medical necessity” for proton beam therapy from your doctor.

  3. Proton beam therapy is outside the plan’s medical network:

    This may be the toughest type of claim to refute.  One way is to show the benefits of proton beam therapy and note that there are no proton beam therapy facilities within the network.

  4. Other treatment methods have the same effectiveness as proton beam therapy:

    Point out that proton beam therapy is noninvasive and has fewer side effects than other treatments.

After a Successful Appeal

Once you have received approval for your treatment, make sure that the costs are covered at the rate described in your plan.  If you find that is not the case, you will need to appeal that as well.

Keep a copy of your approval letter.  While this information should exist in the health plan’s computer system, you can avoid unnecessary delays by having a copy of the approval letter ready to provide upon request.


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