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Aetna Insurance denies treatment for breast cancer patient

A federal lawsuit claims the company chose profit over patients by denying what their doctors call “life changing” treatment.
Published: May. 2, 2022 at 12:02 PM EDT
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ATLANTA, Ga. (CBS46) - Cancer patients say their lives are locked in limbo after Aetna, a major healthcare insurance company, is accused of wrongfully denying coverage claims for “life changing” treatment.

“You can’t even imagine how you’re going to handle something like that,” Claire Thevenot shook her head. “It’s just devastating.”

Thevenot considers herself a fighter. As a nurse and patient care advocate, most days feel as if she’s going to war for others. But today, she’s fighting for herself.

“My first thought was I’m dying,” she recalled.

Stage IV breast cancer, already a medical battle, became a financial one too.

“Your health is put in the hands of someone who really has no idea what’s going on with you and what my situation is,” Thevenot said.

After a double mastectomy in 2018, cancer came back about four months ago. This time, spots spread to her spine. She says, her doctors named Stereotactic Body Radiation Therapy (SBRT) as her best chance for survival.

The technique sends a precise beam with high-intensity radiation doses to a specific cancerous spot, according to UCLA Health. It is a targeted treatment.

Insurance Denial

“We cannot approve this request,” Thevenot read her letter from Aetna. The company says on its website that an estimated 39 million people rely on it.

Aetna denied her insurance coverage for the FDA-approved treatment, requested by her doctors. The patient believes the cost was the primary factor.

“I asked my doctor about paying for this treatment out of pocket and he just said it was tens of thousands of dollars.” Thevenot said adding, “it wouldn’t be something that most people could afford to pay out of pocket.”

Despite medical studies showing the success rate can be 80 to 90% for ridding cancer spots, according to UCLA Health, the Aetna denial letter states there’s no current research that her specific cancer responds better to it than other types of radiation. The letter continues, by saying her plan does not cover services that are not medically necessary.

Aetna Insurance
Aetna Insurance(CBS46)

“The most shocking part of it, I think, is who gets to decide if it’s medically necessary. Common sense would tell you, the doctors get to decide.” Rep. Matt Wilson argued, “the healthcare professionals who have spent their whole career in medicine [should] get to decide.

Georgia State Representative, attorney, and healthcare activist Matt Wilson says his clients, even constituents, too often get denied coverage by employer-sponsored insurance.

“And in Georgia by the way, half of everyone who has insurance gets it from their employer. From their job,” Wilson explained.

Federal Lawsuit Cites Systematic Problem

Insurance denial is far from just a local or state issue. CBS46 Investigates found nationally, insurance denials have jumped 23% in the last five years and 11% just since the pandemic, data from the organization Change Healthcare revealed. Advocates blame insurers for systematically choosing profits over patients.

Some ways the alleged pattern could change would be through new federal regulations or lawsuits.

In a class-action lawsuit filed in Florida, cancer patients seeking similar targeted radiation treatment, argued Aetna wrongfully denied coverage because of costs, it ignored competent medical advice, and it improperly defined what’s considered a medical necessity.

Aetna claims otherwise, denying all allegations. But, a judge just ruled in favor of the cancer patients.

“The court has said ‘yeah, we have listened to the evidence in these particular [two] cases, we agree that Aetna violated their own policy in denying their cancer treatment,” Wilson described. “And, we think maybe this applies to a lot of other people.”

It’s taken about two years for a judge to grant the motion in favor of the patients and it could take many more for potential payment, policy changes, or even legal appeals. It’s time people like Thevenot may not have.

“It’s absolutely time-sensitive, it is. They’re literally making life and death decisions,” Thevenot said.

After being denied twice, Thevenot tried once more by writing a four-page letter. She cited additional studies and research to show why her life depended on the treatment. Aetna finally granted her insurance coverage. The mom finished her targeted radiation several weeks ago.

Meanwhile, the class-action lawsuit is still in its early stage. Aetna is expected to appeal.

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