Case Summary: 12-cv-01548
This is a case about an insurance company denying coverage for a cancer procedure it deems “not medically necessary.”
David Baxter (Baxter) filed suit against his health insurance company (Regence) because of its refusal to cover proton therapy treatment for prostate cancer. Proton therapy is a form of radiation therapy which, like X-ray radiation, destroys cancerous cells. According to Baxter, unlike X-ray radiation, proton therapy delivers the majority of radiation at the tumor site and less in surrounding healthy tissue and allows a higher dose of radiation to get to the tumor while reducing the radiation of surrounding organs, resulting in better cancer control and better quality of life.
According to Baxter, Regence had once approved proton therapy for treatment of prostate cancer. At the time, residents of the Pacific Northwest did not have local access to proton therapy. However, as soon as the Seattle Cancer Care Alliance announced an intent to develop a proton therapy center, Regence changed its policy.
According to Baxter, numerous physicians recommended proton therapy to treat Baxter’s cancer. Following his physicians' recommendations, Baxter received proton therapy for his cancer, paying for it himself. He has sued to recover these costs.
Regence has denied responsibility for payment for proton therapy alleging it fails to fall within the definition of medical necessity in Baxter’s Plan. It claims that such therapy is more costly than alternative radiation therapies and that it has not been established that it results in any better - and sometimes results in worse - clinical outcomes.
The video is of argument on cross motions for summary judgment and is 90 minutes long. The court took the matter under advisement.
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Case-related documents, including those referenced above, are available via the Public Access to Court Electronic Records (PACER) service. For more information, visit Pacer.gov.
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