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April 30, 2019 at 03:48 PM
A federal judge who survived prostate cancer has stepped down from a putative class action lawsuit over a health insurance company’s denial of coverage for a form of radiation treatment.
U.S. District Judge Robert Scola on Monday recused himself from Richard Cole v. United Healthcare Insurance Co. in the Southern District of Florida — a case in which Richard Cole, managing partner at Cole, Scott & Kissane, a prominent Miami law firm, is the named plaintiff.
United Healthcare is part of UnitedHealth Group Inc.’s UnitedHealthcare unit.
Scola wrote that his own life-saving experience with the treatment at the heart of the Cole v. United Healthcare lawsuit — proton beam radiation therapy, which UnitedHealthcare commercial health plans often decline to cover — and a friend’s six-figure medical bills for cancer care prevented him “from deciding this case fairly and impartially.”
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Scola wrote that his friend “fortunately … had the resources to pay $150,000 for the treatment,” but that United Healthcare agreed to reimburse him “only upon threat of litigation.”
“To deny a patient this treatment, if it is available, is immoral and barbaric,” wrote Scola, who did not respond to requests for comment by press time.
Cole, the plaintiff in Cole v. United Healthcare, helps lead Florida’s largest personal injury law firm. He was diagnosed with prostate cancer in April 2018. He filed a putative class action complaint against United Healthcare April 3, after the company refused to cover proton beam radiation therapy for his cancer.
United Healthcare has said it declined coverage because the therapy is experimental and unproven.
Spokeswoman Maria Gordon Shydlo said Monday that UnitedHealthcare “bases its medical policies and coverage decisions — including for proton beam therapy — on the prevailing published clinical and scientific evidence.”
The company responded to a story by CNN in August 2018 that there is “no credible evidence that proton beam therapy is safer or more effective than the proven and covered treatments that are the standard of care for cervical cancer.”
UnitedHealthcare’s Policy Statement
UnitedHealthcare has posted a 19-page general medical policy statement about proton beam radiation therapy on the web.
UnitedHealthcare says in the medical policy statement, which has an effective date of Jan. 1, 2019, that it will cover proton beam radiation therapy without further review for patients younger than 19 years of age, but that, for older patients, it will cover proton beam therapy treatment without further review only for certain conditions, such as eye tumors and tumors in the skull.
UnitedHealthcare says it will consider requests for coverage for some other forms of cancer on a case-by-case basis, when there is documentation that sparing of the surrounding normal tissue cannot be achieved with standard radiation therapy and techniques, and the health care providers compare use of proton beam therapy with other forms of radiation therapy.
Proton beam therapy and another type of therapy, intensity-modulated radiation therapy, “are proven and considered clinically equivalent for treating prostate cancer,” according to the medical policy statement. “Medical necessity will be determined based on the terms of the member’s benefit plan.”
UnitedHealthcare contends that use of proton beam therapy is unproven and not medically necessary, due to insufficient evidence of efficacy, for other conditions, such as breast cancer, lung cancer and pancreatic cancer.
