Families pay for medical insurance so it’s there when they need it most. But what happens when an insurance company calls a procedure experimental but medical experts around the world disagree? That’s exactly what’s happening to a young man with brain cancer in Seattle.
The procedure we are talking about it proton beam therapy. It’s being used on children all over the world. It’s approved by several insurance carriers including Medicare.
Ronnie Castro has brain cancer. Surgery removed most of the tumor. The rest was located near his brain stem and inoperable so doctors recommended Ronnie to have proton beam therapy to kill the rest of it.
Lifewise denied his claim, calling proton beam therapy experimental except in the case of children. The decision is something Ronnie’s wife Kelsey deals with every day.
“Yeah they don’t want to destroy a child’s brain, but then his brain to me is just as important, raising our children, it’s what makes me real angry,” said Kelsey.
Ronnie’s doctors want proton beam therapy because regular radiation uses x-rays that go through the tumor and hit nearby healthy tissue. According to Dr. Ramesh Rengan with Seattle Cancer Care Alliance Proton Therapy Center, protons work differently.
“If I know where a tumor is located, then I know the depth of that tumor, I can modulate and develop a proton beam that will penetrate right to the point where the tumor is and just stop there,” said Dr. Rengan.
Dr. Rengan said the treatment delivers less excess radiation to Ronnie’s eyes and brain stem.
“Not only do you get the benefit of being treated without the critical organ nearby being exposed to radiation, you start getting other benefits reductions in second malignancies, reduction in hormone dysfunction”, Dr. Rengan explained.
However, in a statement Lifewise’s parent company, Premera Blue Cross, defends its denial saying,
“…proton beam radiation therapy lacks reliable evidence, such as conclusive patient studies or trials to demonstrate its effectiveness, thus it is considered an experimental service…”
Dr. Rengan strongly disagrees with that assessment.
“I think when you have a treatment where a six figure number of patients have been treated with, I think it’s difficult to say that we don’t have an adequate level of experience and it’s new,” said Dr. Rengan.
Ronnie’s third appeal was an independent review. It’s required by state law and is performed by a doctor. But the independent group upheld Lifewise’s denial pointing to the provider’s contract.
To get the treatment, the Castro’s needed $39,000.
Friends and family started a Give Forward page and raised enough to cover the treatment. And when Ronnie got better he hired attorney Lish Watson to fight Lifewise.
“In this case health insurers have a black eye. They certainly should have a black eye,” said Watson.
Watson is suing Lifewise and its parent company Premera for denying Ronnie’s claim. He believes he has a great case.
“I believe most of these cases are all about money. And I believe Ronnie’s case is all about money. Otherwise why would they pay for a pediatric patient to get this treatment and not an adult? Where’s the science behind that?” asked Watson.
The fact a child would get the treatment and not Ronnie is a major part of their suit.
“I think it’s an arbitrary decision. They perhaps have fewer children with brain tumors than adults with brain tumors,” Watson concluded.
The suit is currently making its way through the courts and Ronnie is prepared for the fight.
” The lawsuit is intended to help them change their policy and do the right thing. That’s what I want at the end of the day,” said Ronnie.
