In an article published in DOTmed on April 17, 2023, AGG Healthcare Litigation partner Rich Collins commented on the increasing evidence suggesting that proton therapy for some indications can cost less in total than conventional radiotherapy. Although proton therapy may cost more at the outset, it can pay for itself through better long-term outcomes. However, payers classify the treatment as “experimental,” “investigational,” and not “medically necessary” for most cancers.
“The real issue is how do we develop a uniform set of standards and guidelines for proton therapy coverage,” said Rich. “Each insurer drafts its own guidelines, its own exclusions, its own definition of ‘medical necessity,’ typically only revising them when ordered by a court to do so.”
Rich further explained that in addition to saving on side effect treatments, expanding coverage will help insurers save more money by avoiding lengthy and costly litigations and appeals over denials.
“If they do not, then insurers risk losing business with their members and their employers’ business by denying companies the return of healthy workers with no long-term disruptions brought on by avoidable radiotherapy side effects,” he said.
Rich suggested that insurers instead initiate programs that value membership longevity and reward plan renewals.
“They can use their warehouses of claims data to identify providers for network inclusion, or to establish a center of excellence or blue ribbon panel of providers, to expand access while containing the cost of proton therapy,” he said.
To read the full article, please click here.