At least two lawsuits have been filed against UnitedHealthcare in the last two months alleging the insurance company improperly denied patients coverage for a certain type of cancer treatment that insurers have long been reluctant to pay for.
On Monday, U.S. District Judge Robert Scola recused himself from deciding one of the lawsuits filed this month in Miami because of personal experience with the cancer treatment, writing in an order of recusal that denying a patient the treatment "is immoral and barbaric."
"It is undisputed among legitimate medical experts that proton radiation therapy is not experimental and causes much less collateral damage than traditional radiation," Scola wrote. "To deny a patient this treatment, if it is available, is immoral and barbaric."
The treatment, called proton beam therapy, is a radiation therapy used by oncologists to kill cancerous tumors. Compared with traditional radiation, proton therapy is used to target a specific site on the body, limiting damage to surrounding tissues.
According to the complaints, UnitedHealthcare denied coverage for the proton beam therapy for one patient's prostate cancer and another patient's cervical cancer, in both instances determining that the treatment is experimental and unproven. But the patients, who are seeking class action status for their lawsuits, argue that proton therapy is a decades-old effective and established cancer treatment. It was approved by the Food and Drug Administration in 1988 and is paid for by Medicare, according to the complaints.
"Instead of acting solely in the interests of the participants and beneficiaries of its health insurance plans, upon information and belief, UHC denied coverage for PBRT to treat prostate cancer because, on average, PBRT is significantly more expensive than traditional Intensity Modulated Radiotherapy or other treatments," one complaint alleged.
UnitedHealthcare said Monday that it "bases its medical policies and coverage decisions—including for proton beam therapy—on the prevailing published clinical and scientific evidence."
UnitedHealth isn't the only insurer that has denied coverage of proton beam therapy for certain cancers. Last year, an Oklahoma jury told Aetna to pay $25.5 million to a patient's estate after the insurer denied to pay for the treatment based on grounds that it was experimental. Other insurers and policy experts have warned in recent years that there's a lack of evidence showing proton therapy produces better outcomes than other types of radiation. Despite that, hospitals and other companies have rushed to build expensive proton-beam therapy centers.
Richard Cole, the plaintiff in the amended complaint filed last week in a federal district court in Miami, was diagnosed with prostate cancer in April 2018 and his physicians at Baptist Health South Florida recommended proton therapy as an alternative to another type of radiation called intensity modulated radiation therapy, or IMRT, because of the likelihood of a better health outcome, according to the complaint.
UnitedHealthcare, which administered medical benefits on behalf of Cole's self-funded employer, denied his prior authorization request and subsequent appeals for coverage of proton therapy on the grounds that it fell under an exclusion for experimental, investigational or unproven services for patients over 19 years old. Cole paid for the treatment out of pocket.
UnitedHealthcare then changed its policy effective Jan. 1, 2019, to cover proton beam therapy for prostate cancer, acknowledging that proton therapy and IMRT are "proven and considered clinically equivalent for treating prostate cancer," the complaint stated. Still, UnitedHealthcare's independent reviewer continued to deny Cole coverage of the treatment as recently as February 2019.
In the other case filed in March, patient Kate Weissmann, whose employer contracted with UnitedHeathcare for benefits administration, similarly alleged that the insurer repeatedly denied coverage for proton therapy to treat her cervical cancer in 2016 based on a policy that relied on "outdated medical evidence, ignores contemporary medical evidence, and relies more heavily on actuarial calculation of risk pools" because it covers the therapy for patients younger than 19 and older than 65.
She also alleged that UnitedHealthcare relies on an "inadequate review of clinical records" by medical directors who are unqualified to make coverage determinations.
The insurer denied coverage despite recommendations by her physicians at Mass General and the Dana-Farber Cancer Institute that proton therapy was essential for Weissman's treatment for reasons including IMRT put her at risk for bowel and gastrointestinal toxicity while proton therapy reduced that risk. Weissman shelled out $95,000 out of pocket for proton therapy.
The complaints do not state how many patients might be affected by UnitedHealthcare's coverage policy for proton beam therapy. However, the lawsuit filed in Miami noted that 5,000 patients within prostate cancer were treated using proton therapy nationwide in 2018.
Judge Scola wrote in his recusal order that UnitedHealthcare denied coverage of proton radiation treatment requested by his close friend in 2015. UnitedHealthcare agreed to pay for the $150,000 treatment when threatened with litigation. The judge also wrote that he personally was diagnosed with prostate cancer in 2017 and the experts he consulted throughout the country determined that proton therapy was the "wiser course of action" if he opted for radiation.
