On Tuesday a case was filed in the District of Arizona by an ERISA plan benefit recipient against Aetna as third party administrator of the plan. The case concerns the denial of benefits by Aetna for Proton Beam Radiation Therapy (PBRT) as an experimental treatment.
PBRT has been used and recognized as an effective treatment for cancer, especially head and neck cancer, for several decades for cancers in sensitive areas where traditional radiation can cause too much damage to surrounding tissues, the complaint said. This has also been recognized by Medicare Advantage Organizations and other large insurance entities and those entities do not consider the treatment to be experimental or investigational.
The pleading also notes that the safety and efficacy of these treatments have been adopted by the American Society for Radiation Oncology (ASTRO), the National Comprehensive Cancer Network (NCCN), and other nationally-recognized medical organizations.
However, the plaintiff said Aetna has published a Clinical Policy Bulletin regarding this treatment with a large set of criteria for coverage of the treatment and very limited circumstances where the treatment will be covered. Despite the patient and her treating doctors providing medical records, documentation of the treatment’s efficacy and acceptance, and submitting appeals for manual review instead of automated denial of the treatment, Aetna continued to automatically deny the billing, which per the plaintiff violates Aetna’s higher fiduciary duty as a processor of ERISA plan claims.
The plaintiff is suing for recovery of benefits, equitable relief regarding future processing of claims, and attorney fees. They are represented by Kantor & Kantor. No counsel has been entered for defendant to date.
