Virginia Attorney General Jason S. Miyares in December issued an opinion confirming that insurers in the Commonwealth are prohibited from denying coverage for proton therapy for cancer treatment when the coverage determination “is based on the carrier’s application of a higher standard of clinical evidence to such treatment than is used for treatments it otherwise approves.”
This opinion may have far-reaching implications for proton therapy and, more broadly, for the future of insurance coverage for advanced medical treatments.
In response to an inquiry from Virginia Delegate A.C. Cordoza, Miyares wrote:
“Virginia does not mandate coverage for cancer therapy, including proton radiation therapy. …However, an insurance carrier, to the extent it otherwise chooses to provide coverage for cancer therapy, may not deny coverage for proton radiation therapy based on the application of a higher standard of clinical evidence for proton radiation therapy than the carrier uses for other types of radiation therapy.”
The opinion also states that while current law – § 2.2-505 of the Code of Virginia – may not be construed to mandate proton therapy, it does provide that each policy, contract, or plan issued or provided by a carrier that provides coverage for cancer therapy “shall not hold proton radiation therapy to a higher standard of clinical evidence for decisions regarding coverage under the policy, contract, or plan than is applied for decisions regarding coverage of other types of radiation therapy treatment.” There are over 900 peer-reviewed articles, including randomized clinical trials supporting the benefits of proton therapy .
Miyares noted that Delegate Cordoza’s inquiry, on behalf of a constituent who was denied coverage, did not provide details regarding the patient’s condition or justification for the carrier’s denial. Nevertheless, wrote Miyares:
“If the insurance carrier in your scenario is in fact denying coverage for proton radiation therapy based on a failure to meet a higher standard than is imposed on other radiation treatments that would be approved, the carrier is violating [Virginia code].”
Bill Thomas of Hampton University Proton Therapy Institute has been advocating for patients for the past decade.
“We must continue to fight for patients who are denied proton therapy treatment when their doctor recommends it. I am thankful for the support of the Attorney General to hold the insurance companies accountable to the law.”
Virginia has two proton therapy centers. Hampton University Proton Therapy Institute opened in 2010 and Inova Mather Proton Therapy Center opened in 2020.
And while the full impact of the attorney general’s opinion remains to be seen, it is nonetheless a step in the right direction. It ensures that existing law is upheld and safeguards patient access to this life-saving, life-changing treatment.
Miyares’ letter may be viewed in its entirety here: Virginia-AG-opinion-proton-therapy-coveage.pdf
