Aetna wrongfully denied proton therapy claims by court order

A federal judge ruled that Aetna wrongfully denied coverage for proton therapy for cancer patients after the insurance company tried to prove the treatment was experimental and research.

Aetna’s ambiguous definition of “medically necessary” does not justify the exclusion of proton therapy for the treatment of non-metastatic breast cancer or prostate cancer in adults, Judge Kenneth Marra ruled in his decision. summary judgment from the US District Court for the Southern District of Florida on Thursday. The lawsuit will now move to class certification, which could make Aetna liable for a group of patients with similar complaints.

The lead plaintiffs are breast and prostate cancer patients Sharon Prolow and Mark Lemmerman, who won part of their lawsuit seeking proton beam therapy coverage. Marra granted the plaintiffs’ partial summary judgment and said there was no need to bring a claim that Aetna’s failure violated the Employee Pension Act.

“Given the extensive medical literature, detailed medical records, treatment plans, and strong evidence of individual risk factors provided by the attending physicians of Ms. Prolow and Mr. Lemmerman, the Court concludes that the recommendations of the Plaintiffs’ physicians reflect prudent clinical judgment,” the court reads. court statement. stated in the ruling.

Aetna, a subsidiary of CVS Health, did not respond to a request for comment.

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More health systems are offering proton therapy, which uses targeted forms of radiation to fight cancer while limiting harmful effects as the technology becomes less expensive and more effective. But not all insurers pay for its more expensive applications, citing limited evidence that the treatment is more effective than conventional radiation.

Proton therapy is more widely used to treat children with cancer and advanced cancers. But there are more and more use cases and clinical data. UnitedHealthcare and other companies have faced lawsuits regarding their coverage policies.

Aetna wrote in her negative letters to Prolow that “clinical studies have not proven the procedure to be effective for the treatment of a penis condition” i.e. non-metastatic breast cancer. But that reasoning was not linked to any of the five list items that Aetna uses to guide its coverage policy, and those unnamed “clinical studies” were not enough to justify the denials, the court ruled.

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