Aetna Health Plans Won’t Cover PBRT Cancer Treatment Class Action

Health plans do not cover all treatments that might be offered for an illness. This class action takes up the fact that certain health plans administered by Aetna Life Insurance Company and offered by the School Board of Pinellas County does not cover Proton Beam Radiation Therapy (PBRT) as a treatment for cancer. Aetna claims this is because the treatment is “experimental or investigational,” but the complaint alleges that Aetna simply finds it too expensive.

Plaintiff Scott Lake has prostate cancer. He has health insurance his wife’s self-funded Aetna plan through her job with the School Board of Pinellas County. The insurance plan is not governed by the Employee Retirement Income Security Act (ERISA).

Aetna issues and administers the Lakes’ plan and makes payments to providers. Payment funds ultimately come from sponsors or employers who reimburse Aetna. However, the complaint says, “Aetna’s self-funded plans often include stop-loss provisions, which require Aetna to cover and fund benefits above a certain threshold from its own assets.”

Aetna’s Clinical Policy Bulletin No. 270, on “Proton Beam, Neutron Beam, and Carbon Ion Radiotherapy” dates back to 1998 and was last reviewed in July 2019. The complaint notes, “While Aetna’s PBRT Clinical Policy considers PBRT ‘medically necessary’ for persons 21 years old or younger for all types of cancer, it mandates the denial of coverage for PBRT as ‘experimental or investigational’ to treat most cancers on patients over 21 years old.”

In uniformly applying this policy, the complaint alleges, “Aetna has sacrificed the interests of insureds like Mr. Lake … to artificially decrease the number and value of claims it is required to pay from its own assets, specifically with self-funded plans with stop-loss provisions requiring Aetna to cover benefits above a certain threshold and with respect to fully-insured plans requiring Aetna to pay for all benefits from its own assets.”

Why is PBRT desirable? PBRT uses protons to deliver a strong dose of radiation to a tumor but a weaker dose to surrounding tissues and organs. This makes for fewer complications and side effects.

According to the complaint, PBRT “has been well-accepted for over 30 years.” It is used by many cancer facilities, such as MD Anderson Cancer Center and the Mayo Clinic, the complaint says. It notes, “Aetna’s PBRT Clinical Policy Bulletin does not consider PBRT ‘experimental and investigational’ when treating teenagers or children…”

The complaint asserts, “This distinction is completely arbitrary as there are no medical studies that support a conclusion that PBRT would be a proven, safe, and effective treatment for the same cancer in one age group, but not the other.”

The Nationwide Class for this action is all participants or beneficiaries of non-ERISA plans underwritten or administered by Aetna Life Insurance Company, where Aetna cited its PBRT Clinical Policy Bulletin and denied coverage for PBRT to treat cancer in the participant or beneficiary on the grounds that it was “experimental or investigational” and not “medically necessary.” A Florida Subclass has also been defined.

Article Type: Lawsuit
Topic: Insurance
Tags: Denial of Benefits, Health Insurance, Insurance, Treatment or Medication Not Covered