This article is the second in a series on appealing the denial of cancer treatment. The first article may be accessed here.

If your insurance coverage is provided in accordance with the Affordable Care Act (Obamacare) or you have Medicare, your coverage is comprehensive and will cover treatment for cancer.  However, there are many situations in which coverage for cancer treatment may be denied, as the following discussion explains.

Situations in Which an Insurance Company May Deny Cancer Treatment:

Experimental or Investigational Treatment

New targeted therapies for treatment of cancer are being developed daily, but there is often a lag between when a treatment becomes available and when an insurance company will recognize that treatment as the state of the art rather than as a proposed treatment that remains under study.  All health insurance policies contain exclusions for experimental or investigational treatment.  This is a treatment that has not yet completed all of the necessary trials for approval by the Food and Drug Administration or the Centers for Medicare and Medicaid. Even with FDA approval, though, that does not automatically mean the treatment is no longer viewed as investigational.  

The FDA often approves medications for treatment of certain specified conditions only. While it is legally permissible for a licensed physician to use a drug “off-label,” i.e., for a type of cancer for which the drug has not yet been approved, the use of a drug in such manner may still be viewed as experimental.  Other treatments, which have only been approved for use if older therapies have failed may not be covered by insurance even if your doctor is certain that older therapies are unlikely to be successful and wants to use a newly developed treatment as the initial treatment based on preliminary but still incomplete research findings.  

One way you can know for sure whether a treatment is viewed as experimental or investigational is if your doctor or the hospital where you are being treated asks you to sign informed consent documents that explicitly identify the treatment protocol that has been prescribed as being used as part of a research study.  Another tipoff is if you are warned you may be receiving a placebo.  If you believe the treatment that has been recommended by your doctor may be considered experimental, ask the doctor whether there have been issues obtaining insurance coverage for that treatment; and if so, how those issues have been resolved in the past.  

Most insurers have also compiled specific written policies or protocols for certain treatments that are available for the patient (and the doctor) to review on the insurer’s website.  Such policies are periodically updated, but they do not necessarily represent the latest information showing that a medication or treatment has been moved from being considered investigational to approved.  A patient who receives notification from an insurer that a treatment is deemed experimental or investigational should ask their doctor for copies of the latest research establishing the proven efficacy of that treatment for their type of cancer to rebut a claim the treatment is viewed as experimental.

A highly promising form of radiation treatment known as proton beam therapy (PBT) is also often challenged as being experimental.  PBT is able to target tumor-killing radiation into cancers more narrowly than traditional radiation treatment and thus damage less surrounding tissue.  PBT initially gained approval only for use with certain cancers, but as acceptance of PBT for treatment of other cancers becomes more widespread, it is growing less likely that proton beam radiation therapy will be rejected as experimental or investigational.

Medical Necessity

Certain forms of cancer treatment may also be denied as not medically necessary.  Although insurance companies steadfastly maintain that they do not practice medicine, they may question your doctor’s judgment and deem certain medications or therapies, even if FDA-approved, as unnecessary.  Not surprisingly, such assessments usually fall heavily on more expensive drugs or treatments such as stem-cell transplants.  The treating doctor needs to be able to offer a rationale explaining the medical necessity of prescribed treatment and explain why more invasive or expensive treatment is medically necessary and more effective than less expensive treatment.

Out of Network

Insurers are able to reduce medical costs by pre-negotiating reimbursement rates with hospitals and doctors, who are then listed as part of the insurer’s participating network.  Patients usually face significant penalties for receiving treatment from an out-of-network provider or hospital, so even if the treatment is covered by the insurance plan, the patient has to pay more of the charges out of their own pocket.  This can be especially problematic if your care requires treatment by multiple ancillary specialists who may not be within the network.  Patients rarely learn in advance that the medical facility or specialist their in-network doctor recommends is not in the insurer’s network, thus leading to surprise charges after treatment.  

But if the treatment is required in an emergency situation or if the treatment is unavailable from an in-network provider, extra charges for out-of-network treatment can be avoided.  In some instances where a patient needs a particular treatment or procedure for which there are no in-network providers, the insurance company will negotiate what is known as a “single-case agreement” so the patient is able to receive the covered service at the same rate as if the doctor were in the insurer’s network.

Cosmetic/Elective Procedure

Some cancer treatments can result in disfigurement and the need for prosthetic devices.  Federal legislation mandates coverage for breast reconstruction surgery after a mastectomy but similar protections may not exist for other plastic or reconstructive surgery that the insurer may characterize as cosmetic or elective treatment intended solely to improve the patient’s appearance.  If there is truly a medical and functional necessity for such procedures, though, an initial claim rejection may be overcome.

Non-ACA Coverage

Finally, many people have no understanding of what the Affordable Care Act (ACA) means with respect to medical coverage.  Prior to the passage of that law, essential treatments like cancer care could be excluded from coverage or reimbursement would be markedly limited.  The ACA mandates coverage for all essential benefits without annual or lifetime limits on the amount the insurer will reimburse.  However, as a result of changes made to insurance coverage regulation during the Trump administration, many people have been hoodwinked into buying inferior coverage that is marketed as a “short-term” or “association” plans. Consumers should be extremely wary of the coverage they purchase if the price seems unbelievably low in comparison to other quotes they have received – it likely means the cheaper coverage is not comprehensive.  However, if the medical insurance coverage is with recognized insurance company such as a Blue Cross plan, or through entities such as Aetna, Cigna, or Humana, unless the plan is explicitly marketed as a “short-term” plan, it will meet the requirements of the ACA.

Since the United States does not have a national health plan through a single payer or require that all insurers offer identical coverage, the ACA has taken a lot of the guesswork out of buying health insurance.  But even with ACA-compliant coverage, there may be circumstances where cancer treatment is denied by an insurance company.  If that occurs, patients should immediately seek the advice  from an experienced and knowledgeable attorney such as the attorneys at DeBofsky Sherman Casciari Reynolds, P.C.

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