A recent 2018 American Society of Radiation Oncology (ASTRO) study published findings about insurance approval and appeal outcomes at a large-volume proton therapy center, one of the estimated 111 proton therapy centers worldwide. The study showed that proton therapy prior authorization rates were substantially higher for Medicare patients vs. privately insured patients — 91% vs. 30% approval on initial request, at a median 3 days and 14 days from inquiry to determination.
Of the 306 patients initially denied coverage, 276 appealed the decision, and denial was overturned for 189 patients (68%; median time, 21 days from initial inquiry).
It is absolutely essential that proton therapy providers put together strong appeal letters for their patients to increase the chances that insurance decisions are overturned during the administrative claims/appeals review process. If a patient is insured under an ERISA-governed plan then the administrative record becomes, in some cases, the only evidence that a court can examine if proton therapy is denied on appeal leading to civil litigation.
There are exceptions and Kantor & Kantor, LLP can help proton therapy patients overcome various hurdles in the ERISA context. please call us for a free consultation at 888-569-6013. You can use our online contact form as well.