THUNDER BAY — An appeal board has ordered that the Ontario Health Insurance Plan cover the cost of a crucial, potentially life-saving diagnostic scan a cancer patient received in the United States.
Sitting in Thunder Bay, a three-member panel of the Health Services Appeal and Review Board heard evidence in the case in 2017 and 2018, and issued its decision on Jan. 25, 2019.
The general manager of OHIP, in 2015, had rejected coverage for a specialized type of PET scan the man received at the Mayo Clinic.
Provincial regulations allow for payment for out-of-country services if they are accepted practices in Ontario, are medically necessary, and either are not available in Ontario or are required to be done out-of-country to avoid death or medically significant irreversible tissue damage.
The patient underwent the scan, which was not available in Canada, on the recommendation of an Ontario uro-oncologist. The PET scan revealed the recurrence of cancer, for which he was subsequently treated successfully in Toronto.
OHIP refused coverage for the procedure, relying on an evaluation by Cancer Care Ontario that said this kind of scan was considered to be experimental in Ontario, was not accepted here as appropriate in these kinds of circumstances and was not medically necessary in that it was "unlikely to have a significant impact on patient management."
At the appeal hearing, the man's doctor disagreed that the scan was experimental, and noted that no other form of diagnostic imaging would have picked up the location of the recurrent cancer.
A second evaluation of the case by Cancer Care Ontario, conducted two years after the first one, did conclude that the scan is now generally accepted by Ontario's medical profession as an appropriate procedure, but retained its previous findings that it was not medically necessary and was still generally considered experimental.
In approving the patient's appeal, the review board ruled that OHIP had failed to demonstrate "on the balance of probabilities" that the scan is experimental. and found that the procedure did qualify as an insured OHIP service.
The cost of the scan was not included in the board's written decision.
