Isabel Call is a 28-year-old PhD student at UC Davis who, like many UC students, has student health care insurance through Anthem Blue Cross. Unlike most students, Isabel has a rare tumor in her neck. Isabel’s tumor is classified as a malignant neoplasm carotid body tumor. The bulk of Isabel’s tumor was surgically removed in early 2012, but the margin of the tumor which remains in her neck is malignant–meaning that it likely will continue to spread.
Isabel’s tumor is so rare that there is no standard course of treatment, other than to follow the general approach of eradicating the tumor with radiation therapy. Isabel sought treatment at one of the nation’s foremost comprehensive cancer treatment centers. There, she was seen by Dr. Garden, a graduate of Johns Hopkins Medical School and Board Certified Radiologist with 24 years of medical experience and practice in Radiation Oncology. Dr. Garden specializes in the treatment of cancers affecting the head and neck and has published at least 30 peer-reviewed original research articles addressing the treatment of various head and neck cancers. Dr. Garden recommended Isabel undergo a type of radiation therapy called Proton Beam Therapy (PBRT) at the estimated cost of $160,000, compared with IMRT costs of $50,000 to $100,000.
Conventional radiation treatments damage the tissue surrounding the tumor, in part because the radiation release is greatest at surface, and decreases exponentially as it travels into the body. But proton beams can be much more finely controlled, both in width and depth, allowing doctors to more accurately target the tumor. Thus, the proton beams can deliver higher doses of radiation to the tumor with less collateral damage to the surrounding healthy tissues. The lower radiation exposure to surrounding areas typically reduces both short- and long-term side effects of the treatment, including the development of secondary cancers resulting from the radiation, the permanent neck stiffness that results from the scar tissue, and the loss of salivary glands near the tumor and resulting major dental problems. These side effects will affect Isabel’s quality of life for the rest of her life.
Despite the proven benefits of proton beam therapy (Allen, 2012; Yoon, et. al., 2010; Mock, 2004), and even though the therapy is approved for the treatment of more common forms of cancer, Anthem determined that the treatment would not be covered by their insurance because it is considered “investigational” for head and neck cancer due to insufficient clinical data, and will only cover the conventional radiation treatment.
However, unlike Dr. Garden, who recommended the proton beam therapy, as well as Isabel’s radiation oncologist D. Allen Chen at UC Davis Med Center who strongly supports the PBRT recommendation, the Anthem reviewer who denied Isabel’s requested treatment is not board certified in radiology. Rather, he consulted an unidentified doctor “with experience in treating cancer.” There is no indication that the consulting doctor is board certified in radiology or has any experience with cancers of the head and neck. Yet he denied Isabel’s request for treatment, referencing a single article in support.
Isabel appealed the decision. Anthem, however, affirmed the decision to deny treatment based on a second review by a doctor board certified in Obstetrics and Gynecology. While this doctor consulted an unidentified doctor board certified in radiation oncology, neither the consulting doctor’s credentials nor his report are disclosed. Instead, the denial letter conveniently offers to disclose the pertinent information within 30-days of any request. The insurance appeals process already has taken over 4 weeks, and Isabel simply cannot delay her treatment an additional 30 more days to wait for the report.