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The issue in dispute is a treatment known as proton beam therapy, an expensive alternative to standard radiation that, according to advocates, is a more precise form of treatment, with fewer side effects. Opponents questioned whether proton therapy is worth the high cost of fighting some forms of cancer, and insurance companies have often refused coverage, calling it "experimental."
The case before US District Judge Robert N. Scola was brought by a prostate cancer survivor who alleged that UnitedHealthcare had wrongly denied him, along with thousands of others, on the cover of proton beam therapy.
In his challenge, Scola spoke about his own battle with prostate cancer and how he had consulted "the best medical experts in the country" about treatment options. Scola said he had finally opted for surgery, but "all the experts were of the opinion that if I had opted for radiotherapy, proton rays were by far the most sensible measures."
The judge also quoted a friend who had been diagnosed with cancer in 2015 and was charged a $ 150,000 bill after UnitedHealthcare refused to pay for the radiation from its MD Anderson Cancer Center proton beam. . "It's only on threat of litigation that UnitedHealthcare has agreed to pay it back," wrote Scola.
"It is indisputable that legitimate medical experts believe that proton radiation therapy is not experimental and that it causes much less collateral damage than traditional radiation," wrote Scola, District Court Judge. American Southern District of Florida. "Denying a patient this treatment, if available, is immoral and barbaric."
"UnitedHealthcare works every day to ensure its members have access to proven, clinically effective care," said spokesperson Matthew Wiggin. "We cover cancer treatments that have been clinically proven safe and effective, including for some cancers, proton beam therapy.Our medical policies and coverage decisions evolve based on the latest published clinical and scientific evidence. We continually review and update them, policies and hedging decisions. "
The judge's comments were widely shared by patients and physicians who felt challenged by the country's largest insurance company. But like it or not, they have sparked controversy beyond social media.
The American Society of Radiation Oncology (ASTRO), the largest organization of doctors who use radiation to treat cancer, has recognized that the issue is one that fuels passion. Proton beam therapy can cost 60% more than standard radiation, even more than $ 100,000.
"The reason protons are controversial is due to two reasons: because of costs and access," said Dr. William Hartsell, vice president of health policy at ASTRO. "I think if protons were more available and less expensive, there would be many more patients who would be treated with protons."
Proton therapy targets hard-to-treat tumors and allows a greater dose of radiation to reach the targeted area, minimizing damage to other tissues, including vital organs. Standard radiation radiates areas around a tumor rather than a specific location. "We continue to improve the technology to do it better and better," said Hartsell. "So, proton beam therapy is the next step."
"There has been a huge change in the number of studies and the amount of information since," said Hartsell. "But I do not think everyone is aware of that."
"One of the problems we currently have with these [insurance] It is a kind of policy that does not take into account the medical judgment of the people best placed to make that decision. "
He applauded UnitedHealthcare's recent decision to cover the proton beam for prostate cancer, if any.
And some doctors question the judge's comments: the treatment of localized prostate cancer remains a research issue.
"The judge is wrong, he does not know the facts and he cracked for some of the advertising," said Dr. Otis Brawley, professor of oncology at the Johns Hopkins University School of Medicine. and former Chief Medical Officer at the American Cancer Society.
Brawley, who still sees prostate cancer patients, said the physics of "beam proton beam therapy would suggest that it could have fewer side effects compared to conventional external radiation treatment." (IMRT) in the treatment of a number of diseases, including in the treatment of localized prostate cancer. "
"That being said, there is currently no evidence that proton beam radiotherapy offers any advantage over IMRT treatment in the treatment of prostate cancer," he said.
The federal judge made his comments in response to a class action brought by Richard Cole, a cancer survivor and prominent lawyer in Miami. Cole was 70 years old when he was diagnosed with advanced prostate cancer in April 2018. "Your first concern is: am I going to die?" Cole said.
He said he consulted with his team of doctors at the Miami Cancer Institute and other people at the Memorial Sloan Kettering Cancer Center in New York. The consensus, he said, was that he needed a proton beam therapy.
But he said he quickly learned that his treatment was delayed because UnitedHealthcare refused to cover it. He disbursed $ 85,000 for treatment as soon as possible, while his lawyers appealed his refusal.
"When delays occur because of bureaucracy," said Cole, "it makes you angry and annoys you."
His last call was rejected in February, he said, even though UnitedHealthcare had updated its policy a month earlier to allow coverage for prostate cancer. This policy change, he said, was the "obvious evidence" that the trial would last in the courts.
"How can you now change your position without further education and look at a jury or judge with a stern face and say" This man's cancer and many other people's cancer should not be treated exactly that way "? He asked.
His complaint also alleged that a subsidiary of the insurance giant had heavily invested in a proton center in New York.
If his case prevails, said Cole, he will donate any monetary reward to the Miami Cancer Institute. "I certainly know that few people can write a check for $ 85,000, and they should not be excluded from proper treatment simply because they do not have the necessary funds," said Cole, who defended the Insurance companies not those of health – in his job as a lawyer.
His most recent lab results showed that he was clinically cancer free. He attributes his good health to his team of doctors and proton beam therapy. He now wants more Americans to have access to treatment.
His next major obstacle may be to find a judge who will preside over the case. Two other judges also recused themselves because of their friendships with the famous lawyer.
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