Florida man’s lawsuit claims Aetna wrongfully denied coverage for his prostate cancer treatment
A Florida man alleges that Aetna Life Insurance Company wrongly denied coverage for his proton beam radiation therapy treatment for prostate cancer, according to a lawsuit filed this month.
Scott Lake claims that his treatment was wrongfully denied as “experimental or investigational” under Aetna’s generally applicable policy, known as the PBRT Clinical Policy Bulletin. That policy, last updated in November, details that Aetna considers proton beam radiotherapy investigational for prostate cancer in patients over 21 years old because its effectiveness for the disease hasn’t yet been established.
Aetna does, however, consider PBRT “medically necessary” to treat all malignancies in children 21 years or younger, as well as specified tumors. This distinction is “completely arbitrary” given that there are no medical studies to support the treatment in one age group over another, according to the court documents.
In the lawsuit, now moved to the District Court for the Middle District of Florida, Lake also alleges that PBRT has become “so widespread that at a minimum, requests numbering in the hundreds, if not thousands, must have been submitted to and denied by Aetna for coverage of this therapy.”
Furthermore, Lake says he has paid more than $78,000 in out-of-pocket costs for his treatment and “in essence” requests full coverage and/or reimbursement for PBRT, the lawsuit states.
Aetna did not immediately respond to Health Imaging’s request for comment.
Matt joined Chicago’s TriMed team in 2018 covering all areas of health imaging after two years reporting on the hospital field. He holds a bachelor’s in English from UIC, and enjoys a good cup of coffee and an interesting documentary.