“How could it be that BCBS would deny treatment for something Medicare had already approved,” Joe remembered thinking. “Proton therapy is clearly a no-brainer and offers significant advantages over traditional radiation.”
At 76 years old, Joseph Sansbury was focused on enjoying retirement following 36 years as a federal employee. After graduating from The University of Louisville’s Speed Scientific School of Engineering in 1965, he spent his career working as a mechanical engineer at places like Ford Motor Company, Naval Sea Systems Command, and a consulting firm. In his retirement, Joe looked forward to spending time with family, gardening, and traveling.
All of that changed in the fall of 2018.
A routine medical examination found an elevated prostate-specific antigen (PS), which worried Joe’s doctor. After the doctor referred him to a urology specialist, who conducted a series of tests, exams, and a biopsy, the pathology report revealed a Gleason score of 7 (intermediate risk), which meant that the cancer would require treatment. Joe got a second opinion and this time the cancer was determined to be a Gleason score of 9 (aggressive, and high risk). The doctors agreed that he was not be a good candidate for surgery and instead recommended hormone treatments and traditional radiation.
Still curious about different treatment methods, Joe did some independent online research, and discovered proton therapy. It seemed to Joe like a compelling treatment option, but his doctors had never mentioned it.
After reading about the MD Anderson Cancer Center in Houston, Texas and its well-regarded proton treatment center, Joe scheduled a visit. He filled out paperwork, underwent a blood test, and met with the cancer care team. His team agreed that Joe would not be a good candidate for surgery and instead recommended proton therapy along with hormone.
This would only require 39 treatments compared to the 45 traditional radiation treatments that his prior care team originally proposed. Even better, the protons would focus their cancer fighting energy with pinpoint accuracy and focus the radiation on his tumor. Healthy tissues and adjacent organs would only be subject to a minimal level of radiation exposure.
Joe ultimately chose proton therapy with the hormones because of the many advantages it offered.
Nearly eighty percent of Joe’s treatment was covered by Medicare, meaning his supplemental insurance, provided by Blue Cross Blue Shield (BCBS) Federal, would only need to pay the remaining twenty percent. Joe had been paying $400 monthly for supplemental coverage and thought he was covered, but BCBS didn’t agree.
Ahead of his first treatment session, BCBS denied his request for proton therapy. They didn’t see it as “medically necessary.”
Not willing to wait while his aggressive cancer grew, Joe sent MD Anderson an out-of-pocket payment of $8,900 in order schedule his treatment. Simultaneously, he continued to appeal the BCBS denial. His oncologist sent a detailed letter to BCBS explaining why hormone and proton treatments would be the best option for treating Joe’s aggressive form of prostate cancer.
The physician’s letter and the initial appeals were denied. BCBS came back over and over with the same form letter, which read, “[your physician] requested an expedited appeal and for an external medical review with a physician board certified in radiation technology. We have determined that proton therapy is not medically necessary.” They refused to take into account Joe’s unique case, accepted research, and other information supplied by his physician.
“How could it be that BCBS would deny treatment for something Medicare had already approved,” Joe remembered thinking. “Proton therapy is clearly a no-brainer and offers significant advantages over traditional radiation.” The experience and the insurer’s denial left him confused and disappointed.
Joe reached out to his insurance company to ask for further information and clarification about their reasoning. Specifically, he wanted to learn more about the “expert” panel that had reviewed and rejected the request. He was told by a BCBS representative that he wouldn’t be granted access to that information unless it was “subpoenaed” by a lawyer.
While awaiting early morning treatments at MD Anderson, Joe got to know other prostate patients that were also pursuing proton therapy. He calls these other patients his Proton Pals! All of the Proton Pals had Medicare and different supplemental insurance policies but – unlike Joe – none of them had to pay out of pocket for treatment.
Today, Joe has won his battle with cancer but his fight with his health insurance continues. He has paid out of pocket to cover the portion of the treatment not covered by BCBS, which amounted to over $8,900. What was once money Joe saved to enjoy in retirement became a payment to treat a life-threatening cancer—all because BCBS improperly denied his treatment.