Proton Beam denied by insurance

Posted by ajbambe @ajbambe, Oct 24 12:05pm

Anyone ever have proton beam therapy denied by their insurance?
Blue cross and blue shield of Arkansas denied my dad's treatment despite the significant improvement in the level of radiation damage to outlining organs ( based on tumor location) in comparison to regular radiation. Mind blowing differences yet insurance company says no. Despite regular radiation and proton beam therapy costing the same…
My dad had to pay out of pocket and is still working with insurance company on some sort of reimbursement, if any… to actually start treatment.

Interested in more discussions like this? Go to the Proton Beam Therapy Support Group.

Does your dad have Medicare? Medicare does cover proton radiation treatments. But the facility you go to has to approve taking assignment by Medicare. Also other insurance companies also have to be in network of facility you are going to.

BCBS should have covered this treatment but is your plan a HMO type? Is the facility in network for BCBS plan you have?

Did the facility you went to take Medicare? Not all facilities will take certain insurances especially HMOs.

Usually proton radiation is much more expensive than photon. I do not know where you live but can you consider going to to a Mayo Clinic like Phoenix or Rochester. Mayo Jacksonville does not have proton just photon. There are other proton centers also throughout U.S.

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we had the same problem with excellus bkue. went all the way to judge hearing and still denied. He switched insurance to medicare with a supplemental policy. Much more expensive but it was approved immediately. We are currently in fl having 28 day proton treatment!

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He did not have to wait until Oct to switch. insurance broker said he could switch anytime coming off of a private plan.

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Proton bean treatment is more expensive than photon radiation and only about 40 places in the US are licensed to do it.
Does you dad have Medicare? If he has original Medicare (Part A and Part B), he would not have a problem anywhere they take Medicare. But if he got a Medicare Advantage Plan (Part C) instead, then he is very limited, and needs preapproval for treatments. And Mayo does not take Medicare Advantage plans.

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@kkp10

we had the same problem with excellus bkue. went all the way to judge hearing and still denied. He switched insurance to medicare with a supplemental policy. Much more expensive but it was approved immediately. We are currently in fl having 28 day proton treatment!

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Where in Florida are you having the proton treatments?

I had mine done at University of Florida Proton Treatment Institute in Jacksonville Florida. 30 rounds of radiation which lasted 6 weeks.

I had no problem with traditional medicare and my second insurance federal BCBS. Just had my first PSA test and 3 month after treatment visit. PSA went from 3.75 to 1.2. DME good and side affects lessening.

With insurance need to watch PPO versus HMO which most Medicare Advantage are. Some insurance plans limit where you can go to receive treatments based on their in network restrictions.

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@vic83

Proton bean treatment is more expensive than photon radiation and only about 40 places in the US are licensed to do it.
Does you dad have Medicare? If he has original Medicare (Part A and Part B), he would not have a problem anywhere they take Medicare. But if he got a Medicare Advantage Plan (Part C) instead, then he is very limited, and needs preapproval for treatments. And Mayo does not take Medicare Advantage plans.

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vic83, Yes all true. Just put out a letter from Mayo Jacksonville does yearly prior to open Medicare enrollment on Medicare. Medicare Advantage is not Traditional/Original Medicare but a move to a private company who's most plans are HMO which Mayo does not take.

Mayo Clinic is considered a Specialty Hospital/Clinic and Medicare allows them to charge more.

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Mayo in Rochester accepted my MN BCBS Medicare Advantage, my yearly out of pocket cost was $500 after radiation and several consults with urologists and radiation oncologists.

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I had 5 proton beam treatments for prostate cancer in early 2020. Medicare and our excellent retirement health care supplement paid for 98% of the charges. I saw a documentary (somewhat dated now) that suggested that Mayo charges closer to traditional radiation (photon). Not 100% sure about that.
Anecdotally aware of a private proton facility in San Diego where a friend of a fellow prostate cancer patient only got approval from his insurance on the day that his treatment was to start. It’s my impression that Mayo Rochester had things lined up with Medicare and my secondary insurance well before my treatment began. ….
Might also be good to ask questions about treatment protocol – specifically 5 proton beam treatments over two weeks vs 5treatments/week for five (or more) weeks. At the time of my treatment (Feb 2020) Mayo Rochester was using the five treatments over two weeks while Mayo Scottsdale/Phoenix was using the 5 treatment/week for 5+ weeks protocol. Currently, its my impression that Scottsdale is using the 5 treatments over two weeks. (Of course, that may not apply to all patients in either location).
I assume that locations using the longer treatment regime probably charge more than those administering the shorter protocol.
I do not have clarity about why some locations use the longer treatment routine – not sure that the delivery method is exactly the same as for the shorter protocol.
There was a recent report from the UK that a shorter routine (higher dosage) actually had a slightly reduced reoccurrence rate than the longer routine (think this was for photon treatment).

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@marshallfeller

Mayo in Rochester accepted my MN BCBS Medicare Advantage, my yearly out of pocket cost was $500 after radiation and several consults with urologists and radiation oncologists.

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They talked about that on TV in Twin Cities – they commented that in Minnesota if an insurance plan doesn't have Mayo in network, it is harder to sell the policy – so I suspect the Minnesota BCBS Medicare Advantage plan is giving higher payment to Mayo.
Medicare sets the price for a procedure, and the remaining 20% is up to you. A Medigap supplemental policy will pay that 20% based on price Medicare established. A Medicare Advantage plan does not want to pay that 20% and wants to negotiate it down lower to increase their profits. So insurance company establish their own network of doctors who agree TO TAKE LESS than the 20%, and you are required to go to a doctor in their network.
Also, Mayo is only place nearby you can get Proton Beam therapy (There are only some 40+ places in US, Photon radiation (like SBRT) is common, and many places offer it. Also, they want certain tumor characteristics to use Proton Beam. So, your network could not offer best treatment option.
The actual cost is the total of copays for every doctor you saw during the year and any tests before going to Mayo? And the amount of time for referrals and approvals. In two years, I have now had two surgeries, two angiograms, I lost count of how many visits and scans- so do my doctors – I never see a bill and I make an appointment with whatever specialist I think I should see.
I remember my first surgery two years ago and the person pushing my wheelchair at the hospital said that Mayo had stopped taking Medicare – I think he meant Medicare Advantage as I have Medicare Original. There were and still are problems in Florida and Arizona.

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