An Oklahoma verdict against Aetna highlights insurer reluctance to pay for proton beam therapy.
Earlier this month, an Oklahoma jury awarded $25.5 million to a patient's estate and to her widowed husband, deciding that Aetna did not deal fairly with the woman when it denied her claim for a type of radiation called proton beam therapy (PBT), thrusting the treatment into the spotlight.
According to press reports, Orrana Cunningham had stage 4 nasopharyngeal cancer and her doctors wanted her to receive PBT because her tumor was so close to the brainstem.
Aetna, which was ordered by the jury to pay $15.5 million in actual damages and $10 million in punitive damages, refused to cover PBT on the grounds that it was experimental and investigational. Since Cunningham and her husband mortgaged their house to pay for PBT, Aetna was ordered to repay that cost, as well. She died of a viral outbreak in 2015 after receiving the treatment.
Payers have long balked at paying for PBT, which is more precise, helps achieve optimal dose distribution to the site, spares neighboring normal tissue, and avoids unnecessary complications in patients. It also costs 2 to 3 times more than intensity-modulated radiation therapy (IMRT), as the facilities are more expensive to build.
Earlier this year, a review of online advertising and marketing claims made by PBT centers found that not all of the claims directed at consumers were based on guidelines, and that more comparative effectiveness research is needed.1 Some of that research is being undertaken now by the Patient-Centered Outcomes Research Institute.
Aetna wouldn’t comment on the specifics of the case or whether or not it plans to appeal the verdict. In a statement sent to The American Journal of Managed Care®, the company said the denial was “based on the lack of clinical data supporting proton therapy for treating nasopharyngeal tumors” and said that it followed all of the proper steps that were included in her health plan. The insurance company said the denial was upheld through 2 levels of internal appeal. An external review, conducted by an independent radiation oncologist, also upheld the denial, but it was not allowed to be admitted during the trial.
But proponents of the therapy said PBT is not new and has strong evidence to back it up.
“We don’t advocate to say that proton beam therapy is for everyone,” said Daniel Smith, executive director of the Alliance for Proton Therapy Access, a patient advocacy and lobbying group funded by proton beam therapy manufacturers. But, he added, PBT is the recommended treatment for many people depending on their type of cancer, and doctors and patients should be making these decisions, he said, not insurers.
“I think that the insurance companies are often looking at cost,” Smith said, who added that if PBT can offer improved results, then “price is not the most important thing here.” Long-term costs could be lowered if complications are fewer and other medical costs are not as high, he said.
On its website, the group highlights patient stories, and said that about 66% of patients who seek proton therapy have their claims denied; when they appeal, 4 out of 10 of those people are denied again.
Andrew L. Chang, MD, who testified as an expert witness on behalf of the Cunninghams in the case, said that in 2014, when she first sought coverage for PBT, the therapy was not yet included in head and neck guidelines from the National Comprehensive Cancer Network (they have since been added). They were, however, included in guidelines from the American Society for Radiation Oncology guidelines.
“I think my impression is that the company was negligent in understanding what the recommendations were for her cancer,” said Chang, who directs a PBT center in California.
As one example, he noted some trial evidence: 90 color pages of documentation showing how PBT would work for Cunningham’s specific tumor, which were faxed to Aetna. When the pages were shown in the courtroom, the colored diagrams were rendered as unreadable black boxes because of the fax, and the jurors realized no one at the company had really reviewed the information, he said.
For its part, the Alliance for Proton Therapy Access is trying to push forward a “Cancer Patient’s Timely Treatment Bill of Rights.” It is general to all cancer treatment, not just PBT, and is aimed at state insurance commissioners. The proposal seeks time limits for coverage requests and appeals and sets qualifications for the physicians reviewing cases on behalf of insurers.
1. Corkum MT, Liu W, Palma DA, et al. Online advertising and marketing claims by providers of proton beam therapy: are they guideline-based? [published online March 15, 2018]. Radiat Oncol. doi: 10.1186/s13014-018-0988-z.