https://www.propublica.org/article/blue-cross-proton-therapy-cancer-
lawyer-denial

Blue Cross and Blue Shield denied payment for the proton therapy Robert
�Skeeter� Salim�s doctor ordered to fight his throat cancer. But he was no
ordinary patient. He was a celebrated litigator. And he was ready to
fight.

In August 2018, Robert Salim and eight of his friends and relatives flew
to the steamy heat of New York City to watch the U.S. Open.

The group � most of them lawyers who were old tennis buddies from college
� gathered every few years to attend the championship. They raced from
court to court to catch as many matches as possible. They hung out at
bars, splurged on high-priced meals and caught up on each others� lives.

But that year, Salim had trouble walking the half-mile from the subway
station to the Billie Jean King National Tennis Center in Flushing Meadows
without stopping two or three times to rest. Back in his hotel room, he
was coughing badly, his phlegm speckled with spots of blood. Although he
had kept fit for a 67-year-old, he felt ragged.

Salim, whose friends call him Skeeter, flew home to Houston, where he saw
his family doctor. After dozens of tests and visits to specialists, he
received his diagnosis: stage 4 throat cancer. A tumor almost an inch long
was growing under the back of his tongue, lodged like a rock. It had
spread to his lymph nodes. Dr. Clifton Fuller, his oncologist at the MD
Anderson Cancer Center, called it �massive oral disease.�

Still, Fuller told Salim that his type of throat cancer would respond well
to a treatment known as proton therapy, which focuses a tight beam of
radiation on a tumor. So Fuller�s staff quickly sought approval from
Salim�s health insurer, marking its fax �URGENT REQUEST�: �Please treat
this request as expedited based on the patient�s diagnosis which is
considered life threatening.�

The answer arrived two days later. Blue Cross and Blue Shield of Louisiana
would not pay for proton therapy; the costly procedure was appropriate
only after doctors had previously tried other methods for irradiating the
head and neck. �This treatment is not medically necessary for you,� the
rejection letter read.

Fuller told Salim that he might have to use a cheaper form of radiation
that is less precise. Normally outgoing and optimistic, Salim felt his
chest tighten as Fuller described the possible side effects of that other
type of treatment. Because there were many critical organs near Salim�s
tumor, the damage could be severe, causing loss of hearing, diminished
sense of taste and smell, and brain impairment, like memory loss.

At that point, Salim seemed in danger of joining millions of other
Americans denied payment for medical treatment. These patients often
settle for outdated, riskier procedures or simply forgo care.

But Salim was no ordinary patient. He was, in fact, an aggressive
litigator who had been named one of the 100 best trial lawyers in America.
In a long career working from Natchitoches, Louisiana, a tiny city in the
Creole heartland, he had helped extract settlements worth hundreds of
millions of dollars from massive corporations that had harmed consumers
with unsafe products, including pelvic mesh and the pain reliever Vioxx.

Salim decided to do what few people can afford to do. He paid MD Anderson
$95,862.95 for his proton therapy and readied for a battle with Blue
Cross, the biggest insurance company in Louisiana. As always, Skeeter
Salim was determined to win.

It would be Goliath vs. Goliath.

�It�s not about the money for me. I�ve been blessed and we have an
extremely lucrative practice,� said Salim, a broad-set man quick with
jokes. �But I would like to see other people that are not in the same
situation not get run over by these people. There�s no telling how many
billions the insurers made by denying claims on a bogus basis.�

Blue Cross and Blue Shield of Louisiana declined to comment, citing
ongoing litigation.

In his decades as a plaintiff�s lawyer, Salim had relied upon consumer
protection laws and billion-dollar judgments to make companies fix their
bad practices. But now he stood on different terrain, facing a 1970s-era
federal law that deprived patients of tools to fight, let alone change,
abuses by the insurance industry.

And interviews, court documents and previously confidential emails and
records from Blue Cross, its contractors and MD Anderson would expose the
inner workings of a large insurer and an unnerving truth: To overcome a
system tilted heavily in favor of the insurance industry, you need money,
a dogged doctor and a friend with unusual skills.

�Arbitrary and Capricious�
Salim was angry. For years, he had paid Blue Cross more than $100,000 in
annual premiums to cover himself, the employees of his law firm and their
family members.

In mid-October 2018, he scrawled a note on a legal pad: �Blue Cross�
denial is arbitrary and capricious and will lead to irreversible harm to
my physical being.�

https://img.assets-
d.propublica.org/v5/images/IMG_3138_crop.jpg?crop=focalpoint&fit=crop&fm=w
ebp&fp-x=0.5&fp-y=0.5&h=967&q=75&w=1450&s=464485c0337fd8c79a81637b604dc1f0

A note Salim wrote complaining about Blue Cross� denial of payment for his
medical care Credit:Courtesy of Robert Salim

And so Salim began his unusual journey to appeal an insurance company
rejection. Few patients ever do so. One study of Obamacare health plans
purchased on healthcare.gov found that less than 1% of people tried to
overturn claim denials.

When a patient files an appeal, insurance company doctors are supposed to
take a fresh look to reconsider the denial, relying on medical guidelines,
their own clinical experience, scientific studies and the recommendations
of professional societies.

But the insurance industry doctors who shot down Salim�s appeal did little
to consult outside sources, a ProPublica review found. They cut and pasted
guidelines created by a company called AIM Specialty Health: �The
requested proton beam therapy is not medically necessary for this
patient,� one rejection letter read.

Many insurers won�t pay for certain specialized or expensive treatments
unless a patient gets approval in advance. Blue Cross and other health
plans often farm out those reviews to companies like AIM. The insurance
industry maintains such companies keep health care costs down and help
patients by rejecting unnecessary and unproven treatments. Critics say the
companies unfairly deny claims, noting that they market themselves to
insurers by promising to slash costs.

In Salim�s case, AIM made decisions using its own guidelines, which it
said at the time were based on medical studies and the recommendations of
professional medical associations. AIM�s parent company, Anthem, renamed
itself Elevance Health in 2022, and subsequently changed AIM�s name to
Carelon Medical Benefits Management. In a statement, Elevance said that
Carelon �uses evidence-based clinical guidelines to assess requests.�

At Blue Cross, Salim�s appeal started with a review by one of its own
doctors, an ear, nose and throat specialist. He affirmed the denial using
language taken directly from AIM�s guidelines.

The insurer then routed Salim�s request to an outside company called
AllMed that it had hired to render expert opinions. A day later, AllMed�s
doctor, a radiation oncologist, affirmed the decision to deny payment for
Salim�s care. He, too, copied AIM�s guidelines in explaining his reasons.
AllMed did not return requests for comment.

Not willing to give up, Fuller, Salim�s doctor, took a step physicians
rarely do: He asked Blue Cross to have an independent medical review board
unaffiliated with the insurer or AIM examine Salim�s claim. Louisiana�s
Department of Insurance randomly selected the review company, Medical
Review Institute of America.

Fuller didn�t skimp on evidence. He sent the company a 225-page request
containing Salim�s medical records, MD Anderson�s evaluation and outside
studies supporting the use of proton therapy.

The next day, the Medical Review Institute denied the claim. Its doctor, a
radiation oncologist, not only quoted AIM�s guidelines, but also cited
four studies that raised questions about the evidence for proton therapy.
The Medical Review Institute did not return requests for comment.

In 19 days, five different people at four different companies had reviewed
Salim�s case. Each had denied his request for treatment. Each had cited
AIM�s guidelines. The appeal process was over.

Before the review was complete, Salim had decided to pay out of pocket for
the proton beam therapy. �If there�s a tumor in there, and it�s growing,
why are we waiting so long to do something?� he asked Fuller.

Over more than two and half months that fall and winter, Salim visited MD
Anderson multiple times a week. At each radiation session, he strapped on
a custom mask that covered his entire face. Nurses locked him into arm and
leg restraints. Then he had to hold still for 45 minutes while the proton
therapy machine thrummed around him.