PRUDENTIAL DENIAL OF COVERAGE OF BREAST CANCER BONE MARROW TRANSPLANTS

Executive Summary

PRUDENTIAL DENIAL OF COVERAGE OF BREAST CANCER BONE MARROW TRANSPLANTS draws a lawsuit filed by & Texas Attorney General Dan Morales Sept. 23. The suit against the Prudential Insurance Co. of America charges the insurance company with not providing coverage to breast cancer patients receiving autologous bone marrow transplants with high-dose chemotherapy. Among other entreaties, the Texas petition requests that Prudential be enjoined from "misrepresenting that high-dose chemotherapy for breast cancer is experimental and/or investigational, when it is not; [and] misrepresenting that high- dose chemotherapy for breast cancer is not medically necessary, medically accepted treatment, when it is." Furthermore, the petition maintains that Prudential should be prohibited from misleading insured individuals by "interpreting the experimental and investigational exclusion so broadly as to exclude coverage for any treatment under study or for state-of-the-art, medically necessary treatments." The Texas Attorney General's office contends that since the procedure is administered in such "first-rate" medical centers as M. D. Anderson Hospital, the University of Texas and Baylor University, ABMT for breast cancer administered in conjunction with high-dose chemo is not an investigational treatment, but rather has been "recognized as safe and effective." Claiming that Prudential violated the Texas Insurance code, the petition asks that the company pay civil penalties up to $10,000 to each individual who failed to receive coverage. Prudential said the company intends to "vigorously defend the suit." The company has paid for breast cancer treatment using ABMT with high-dose chemotherapy, although the patient involved was being treated under the direction of a National Cancer Institute protocol, Prudenti al said. Prudential maintains that its future policy regarding coverage of breast cancer patients receiving autologous bone marrow transplant/high-dose chemotherapy will be "heavily influenced" by the results of four ongoing NCI breast cancer clinical trials that are examining the safety and efficacy of the procedure. NCI reported that the four national studies, consisting of two Stage 4 and two Stage 2 breast cancer trials, are currently active and enrolling patients. While information suggests that the procedure can be performed with relative safety and benefits, existing data do not definitively demonstrate that the procedure is superior to conventional treatments, an NCI official said. At this time, the NCI representative said, the confusion lies predominantly in the conflicting legal and biomedical definitions of the term "experimental." Coverage of investigational treatments is addressed in the preliminary draft of President Clinton's health care reform proposal. Normal medical expenses incorporated in the use of investigational treatments during an approved trial would be covered by the proposed benefit package. Prudential is the second insurer to be sued in recent weeks for its policy concerning the reimbursement for breast cancer treatments. Empire Blue Cross and Blue Shield is being sued by Memorial Sloan-Kettering Cancer Center for its failure to cover high-dose chemotherapy and Bristol-Myers Squibb's Taxol (paclitaxel) treatments for breast cancer patients ("The Pink Sheet" Sept. 27, T&G-9).