A Lake Placid, New York resident has filed a proposed class action to challenge Excellus BlueCross BlueShield’s apparent denial of coverage for proton beam therapy to treat prostate cancer.
The plaintiff, who the suit says has prostate cancer, alleges in the 20-page lawsuit that Excellus BCBS has wrongfully denied coverage for the treatment, by which a tumor is targeted with a radiation beam made of ionizing particles, given proton beam therapy has been shown to be an effective, often preferred option to treat cancerous tumors. According to the lawsuit, Excellus BCBS has denied the plaintiff’s coverage on the grounds that proton beam therapy is “not medically necessary for the treatment of prostate cancer.”
“Defendant’s position is contrary to the science, relies on outdated source material, conflicts with Defendant’s coverage position when Medicare pays for proton beam therapy, and is an abuse of its discretion,” the complaint charges.
Proton beam therapy relies upon protons to deliver curative doses of radiation to a tumor while reducing doses to healthy tissues and organs, which results in fewer complications and side effects than traditional radiation therapy, the lawsuit explains. Per the case, proton beam therapy enables patients to tolerate higher doses of radiotherapy in comparison to traditional radiation treatment, and can be adjusted and shaped to match the size of the cancerous tissue to be destroyed while sparing, for the most part, healthy tissue.
The lawsuit stresses that studies have shown proton beam therapy to be effective in treating tumors of the prostate; brain, head and neck; central nervous system; lungs; and gastrointestinal system in addition to cancers that cannot be completely removed by surgery. The case also describes proton beam therapy as “often the preferred option for treating solid tumors in children” given protons can be controlled precisely and are associated with fewer complications and a reduced chance of secondary tumors.
Further still, the complaint notes that the Food and Drug Administration approved proton beam therapy for the treatment of cancer in 1988, and many other nationally recognized medical groups, not to mention cancer treatment facilities and providers, regularly recommend and use the treatment.
Although the plaintiff’s doctor recommended proton treatment for his prostate cancer, Excellus BCBS nevertheless denied coverage in February 2021, stating in a letter that “there is no research” showing that the plaintiff’s type of cancer “responds better to the requested type of treatment than the type of treatment that Excellus can approve,” that being intensity modulated radiation therapy.
Excellus’ denial of coverage for the plaintiff amounts to a breach of its contractual and fiduciary duties, the suit alleges, arguing that the defendant’s position is “even harder to defend…when Medicare pays for the services.”
“Excellus provides Medicare coverage under the trade names BlueBasic and BluePlus. Both plans cover proton beam therapy for treatment of prostate cancer,” the case says. “Thus, if [plaintiff] was three years older, his proton beam therapy treatment would have been medically necessary.”
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