Proton beam coverage suit against UnitedHealthcare moves forward

AdventHealth may be liable for non-employed physician, appellate court rules


A federal judge refused to toss a proposed class-action suit against UnitedHealthcare, with plaintiffs alleging the Minnetonka, Minn.-based insurer improperly denied benefits and did not live up to its fiduciary duty to cover a type of cancer treatment known as proton beam therapy.

U.S. District Judge Allison Burroughs denied UnitedHealthcare’s motion to dismiss on Monday. In March 2020, a court dismissed an individual claim on behalf of Kate Weismann, who paid $95,000 out-of-pocket for proton beam therapy to treat her cervical cancer. The court said that she would have to sue under a different provision of the Employee Retirement Income Security Act, or ERISA. While Weismann accused UnitedHealthcare of breaching its fiduciary duty, the judge said she should have sued the insurer for denial of benefits. Weismann amended her complaint and the court eventually consolidated her case with two others accusing UnitedHealthcare of wrongfully denying proton beam therapy for cancer treatment.

UnitedHealthcare argued that the therapy had not been proven to be more effective than standard radiation. The updated complaint alleges that the insurer did not take the time to review individual prior authorization requests, improperly categorizes the FDA-approved treatment as “experimental” and denied coverage because it was more expensive than traditional chemotherapy. Plaintiffs are seeking both equitable reimbursement for damages as well as repayment for the out-of-pocket costs they paid for the treatment.

The plaintiffs’ attorney, Tim Rozelle of Kantor & Kantor, called the updated ruling a “watershed” moment for both patients seeking proton beam therapy and providers who administer the treatment.

“Let’s let the science drive, the medical community drive, what is medically necessary and what’s not experimental,” Rozelle said.

Insurers have long been reluctant to cover proton beam therapy, which is more expensive than traditional radiation therapy. Rozelle said this leads to hardship for patients, as well as proton beam therapy providers. A number of proton beam therapy providers have gone bankrupt in recent years thanks, in part, to inadequate reimbursement from insurance companies. By pursuing class-action status on behalf of ERISA members enrolled in policies through the nation’s largest insurer, Rozelle said the case had the potential to impact thousands of lives.

A UnitedHealthcare spokesperson said that the company relies on guidance from medical societies, published studies and evidence-based protocols to make coverage decisions. The insurer said it will continue to “vigorously defend the matter in court.”

“We cover cancer therapies including, for some cancers, proton beam therapy,” a spokesman wrote in an email. “We continually review and update our medical policies and coverage decisions based on the most current published clinical and scientific evidence.”

Proton beam therapy is a radiation therapy used by oncologists to kill cancerous tumors. Compared with traditional radiation, proton therapy is used to target a specific site on the body, limiting damage to surrounding tissues.



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Marie Maynes
Marie Maynes is a Sports enthusiast and writes for the Sports section of ANH.