Why Do Insurance Companies Say “No” to Proton Beam Therapy? What Prostate Cancer Patients Need to Know

Facing a cancer diagnosis is one of the most frightening experiences a person can endure.

From overwhelming emotions to rapidly changing medical terms and decisions, patients must navigate a maze of tough choices while struggling to maintain their health, stability, and hope. 

But the emotional toll is only part of the battle. 

One of the most critical fights many patients endure comes not against the disease itself, but against their own health insurance companies.

Increasingly, insurance providers are denying coverage for a powerful, targeted form of radiation treatment called proton beam therapy, a treatment that could significantly reduce harm to healthy tissue and improve patient outcomes. 

Instead, insurers push patients toward a less expensive alternative, IMRT (Intensity-Modulated Radiation Therapy), even when proton therapy could be medically superior and involve less risk. That raises an urgent question for patients and families alike:

When the best medicine is available but insurance says “no,” what happens next?

Understanding Proton Beam Therapy vs. IMRT

Proton Beam Therapy: Precision with Purpose

Proton beam therapy is an advanced form of radiation treatment that uses protons (highly charged particles) to deliver radiation in a laser-precise fashion. 

The unique physics behind protons allows them to release most of their energy only at the tumor site, minimize exposure to surrounding healthy tissue, and reduce long-term side effects such as nerve damage, gastrointestinal complications, and secondary cancers.

Unlike traditional radiation, which behaves more like a broad flashlight, protons essentially stop once they deliver their dose, leaving healthy cells largely untouched.

Because of this precision, proton therapy is often recommended for tumors located near critical structures, such as the brain, spinal cord, eye, or heart, and for pediatric patients whose developing bodies are especially vulnerable to collateral radiation damage.

IMRT: A Cheaper but Broader Approach

IMRT is a form of external beam radiation therapy that shapes the intensity of X-ray beams to better contour tumors than older “one-size-fits-all” radiation methods. 

It’s an improvement over basic external radiation, but it still delivers radiation across a wider area than proton therapy, affects healthy tissues beyond the tumor, and can cause significant adverse effects depending on the site and dose.

Because IMRT’s technology is well-established, widely available, and significantly cheaper, typically costing $18,000 to $30,000 per course, it’s often the default option insurers prefer.

By contrast, proton beam therapy can run $150,000 to $180,000 or more per course, making it a target for insurance cost-cutting.

Why Insurers Deny Proton Beam Therapy Coverage

Most people assume insurance companies base treatment coverage on what’s medically best for the patient. But in reality, the decision often comes down to cost, coverage guidelines, and internal policies designed to limit expensive treatments whenever possible.

Here’s what usually happens:

Insurers Call Proton Therapy “Not Medically Necessary”

Insurance companies regularly deny proton therapy claims on the basis that the treatment is not “medically necessary,” “experimental,” or “investigational.” 

They argue that IMRT is an acceptable standard of care, that proton therapy hasn’t proven itself “clinically superior” across all conditions, and that the benefits don’t justify the cost.

Even when a patient’s oncologist, often one of the country’s top specialists, attests that proton therapy is the best option, insurers will still deny coverage unless the company’s internal criteria are satisfied.

Insurers Prioritize Cheaper Alternatives

Insurance companies are under pressure from shareholders and corporate leadership to reduce spending. Radiation therapy costs represent an area where insurers can save hundreds of thousands of dollars per patient by steering patients toward IMRT.

Because IMRT is cheaper and seen as “good enough” for many cancers, insurers use it to justify their denials, even though “good enough” isn’t necessarily what’s best for the patient.

Policies Don’t Keep Up With Medical Innovation

Medical innovation is advancing faster than insurance policy updates. Proton therapy, once rare, is now widely considered superior for certain cancers, yet many insurers haven’t updated their policies to reflect that.

This regulatory and policy lag gives insurers room to deny coverage even when medical evidence supports proton therapy use.

What Happens When Insurance Denies Proton Beam Therapy?

Insurance denials can be frustrating but can also completely jeopardize a patient’s health.

Harm to Healthy Tissue

When IMRT is used instead of proton therapy, healthy tissues surrounding the tumor receive more radiation. This can cause:

• Heart damage
• Lung inflammation
• GI tract injury
• Neurological side effects
• Secondary cancers later in life

For many patients, these side effects are not minor. They may lead to chronic disability, additional surgeries, lifelong medical care, or even premature death.

Lost Time and Emotional Toll

Insurance appeals take time, often weeks or months. For cancer patients, time is critical. Delays in beginning the most appropriate treatment can allow tumors to grow or spread, reducing the odds of survival.

Financial Burden and Unnecessary Costs

Whether a patient pays out-of-pocket or maxes out high deductibles while appealing a denial, the financial toll can be devastating. Many families sacrifice savings, retirement funds, and even homes trying to secure the treatment they need.

How Patients Can Fight Insurance Denials

Insurance companies rely on patient passivity. But patients have rights, and there are multiple ways to challenge a denial.

Internal Appeals

Every insurance policy subject to state or federal law, including ERISA for employer-based plans, requires that insurers provide an internal appeal process. This is the first step.

Patients and their doctors can submit:

• Detailed medical records
• Letters of medical necessity
• Evidence from peer-reviewed journals
• Expert opinions establishing proton therapy as superior

An internal appeal can reverse a denial, but insurers often deny appeals, too, requiring escalation to external review.

External Review

Many states and federal ERISA plans allow for an independent external review. In this process:

• A neutral third party reviews the insurer’s decision
• The reviewer evaluates whether the treatment meets clinical necessity standards
• The decision can be binding on the insurer

External reviews succeed when the appeal is carefully framed using current medical evidence and expert testimony.

Legal Action

When internal and external appeals fail, and when an insurer acts unreasonably or in bad faith, legal action may be necessary.

A lawsuit against an insurer can allege:

• Breach of contract when an insurance company is failing to uphold policy terms
• Bad faith denial when an insurer knowingly or recklessly denies coverage without a reasonable basis
• Violations of state and federal health benefit laws

Successful litigation can not only force coverage of the denied treatment but also recover damages for:

• Emotional distress
• Financial losses
• Attorneys’ fees
• Penalties for bad-faith conduct

According to Medical Evidence, Proton Therapy Isn’t “Experimental” but Rather Cutting-Edge Care

One of the main reasons insurers deny coverage is the claim that proton therapy is “experimental.” But in many cancers and clinical situations, that claim no longer reflects medical reality.

Proton therapy has been used for decades, with thousands of peer-reviewed studies demonstrating its safety and effectiveness, as well as clinical guidelines from respected cancer organizations recommending its use. There is also particularly strong evidence in pediatric cancers, skull base tumors, CNS malignancies, and head and neck cancers

For difficult tumor locations, such as near the optic nerves or brain stem, proton therapy is often not only better but the only viable option that offers meaningful tumor control without devastating side effects.

Doctors routinely recommend proton therapy when IMRT would cause unacceptable toxicity. These expert recommendations are compelling evidence in appeals and legal challenges.

What This Means for Patients and Families

When an insurance company denies proton beam therapy, patients are left with three difficult options:

1. Accept the denial and proceed with the insurer’s recommended treatment (e.g., IMRT), even if it’s not the best option
2. Pay out-of-pocket for proton therapy, potentially bankrupting themselves and their family
3. Fight the denial through appeals and legal action

Most families choose the third, and that’s where Morgan & Morgan steps in.

How Morgan & Morgan Can Help You Win Coverage for Proton Beam Therapy

At Morgan & Morgan, we know that behind every insurance denial is a human being suffering through one of life’s hardest battles. We also know that insurers don’t always make decisions based on science or patient welfare; they make them based on cost.

At Morgan & Morgan, we have helped families fight back against insurance companies for over 35 years and have helped recover over $30 billion in compensation in the process. 

Our compassionate legal team helps victims to understand their rights under ERISA and state insurance laws as we assemble compelling evidence from medical experts and clinical research.

We can help those denied the assistance they deserve navigate internal and external appeals with precision and can file bad-faith insurance lawsuits when insurers refuse to do what’s right.

We treat every client with dignity, transparency, and fierce advocacy, because we know what’s at stake.

Don’t Let an Insurance Denial Decide Your Cancer Care

No one should be forced to accept inferior treatment because an insurance company wants to save money. When a doctor says proton beam therapy is medically necessary, insurers should follow the science, not their spreadsheets.

If you or a loved one has been denied coverage for proton beam therapy, you have options and legal rights.

Contact Morgan & Morgan today for a free case evaluation. We’ll review your insurance plan, medical records, and denial letters, and help you decide the best path forward. You deserve the best care possible, and we’ll fight to help you get it.