A New Form of Insurance Denial of Coverage

Doctors hate the first of the year. Besides the cold weather, there are a myriad of reasons for that. In private practice one typically goes without a paycheck for two months. That’s a bit of a stressor. Increasingly more frustrating every year is all the changes from pharmacy benefit managers. Finally the physician finds the right combination of antihypertensive drugs, blood pressure is well controlled, life is good! Then the dreaded letter from the pharmacy benefits company arrives, stating that Exforge (or Metoprolol ER or…) is not covered under the patient’s insurance plan. For some reason this year it is extended release medications on seniors’  plans that are not covered, generic no less. The elderly patient, who may be challenged in regard to compliance, now must take his or her medicine two or three times a day instead of just once. No problem, I’m sure the insurance company will send out a nurse to make certain that the patient takes all medications properly. No wait, the nurse is busy sending the patient to the emergency room for a hangnail because she’s worried that pain in the left arm is cardiac. But I digress.

Screenshot 2014-03-25 06.46.47

Copy from denial letter

This week a new level of denial has been breached. Now medications are deemed “experimental”. Somehow pharmacy benefit managers have confused off-label with experimental. Why would they do that? Simple: off-label use isn’t excluded on a patient’s insurance but experimental is. In one particular case my patient has a progressive debilitating neurologic disease that is causing pain. The patient already has issues with constipation due to an inability to be mobile so narcotics are not a good option, not to mention that he does not want to be dependent on narcotics for this pain. Amazingly this “experimental” medication was doing a  good job of managing the pain for the last year or so.

Not only is the denial of this medication arbitrary and cruel, it is unethical. Off label use of medications is an accepted and necessary treatment choice, particularly with pain, where avoiding narcotics is important for patient quality-of-life and many off-label use of medications is well-studied but not in the drug’s package insert since the medication has long been generic. In the meantime the patient asks ME how to deal with the issue. I recommended that they call their insurance company to begin an appeal process. Frankly a good lawyer might be a good idea as well.

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One thought on “A New Form of Insurance Denial of Coverage

  1. Insurance companies started aggressively policing doctor decisions, and healthcare got more frustrating and costly. Intruding on therapy or prescriptions causes delays and sometimes unnecessary office visits. I broke my shoulder several years ago, and after it healed, it was frozen in place. I needed physical therapy three times a week for months. I was slowly making progress, and PT would send flexibility and progress measurements to my orthopedic doctor. Even so, the insurance company would sometimes require an evaluation office visit with the doctor. He has a busy practice, so a few times my therapy got put on hold until the doctor could see me and get another prescription written to send in. Several times I had to wait a week for this to clear the process, and my progress went backwards. So it sort of went two feet forward and one foot back.. I ended up needing almost 4 and a half months of therapy, and I probably could have done it in three months if they had just trusted the PT’s reports and the doctor’s sign off on more therapy. They had to pay for 3 evaluation visits that otherwise wouldn’t have been needed, and also for more PT.
    I have ongoing stomach issues, and my doctor has prescribed a premium brand name medication and it isn’t yet generic. I’m careful to make sure I don’t run out, but there always has to be an appeal when this prescription is written. It takes time and a patient could spend time without the medication if he/she isn’t very organized about re-ordering. Because of bleeding ulcers, I can’t take anti inflammatory drugs very often, and for chronic pain they are not a good choice. I have arthritis in my back, hands, and tendonitis / bursitis in my arms and hips. My doctor prescribed a couple of gels and patches that work well, but they were denied and we couldn’t get them through without letters from me and from him. It just seems as though they can’t see that some patients require something different, and they think they know more than my doctor.
    When I had stomach surgery, the insurance company required me to talk to a nurse once a week, one who was a patient advocate. She would spend quite a bit of time questioning me about my symptoms, recovery, diet, medication, daily schedule, etc. and had all kinds of unsolicited advice. My stomach surgeon has a great staff and extremely good after care; I didn’t need anyone else to advise me. The nurses at his office were available to me anytime I had a problem. The insurance company was spending money in a place they really didn’t need to.
    Personally, the thing that has hurt me the most is that I can no longer talk to my long time therapist. I saw him for 3 years as he assisted me in dealing with grief over my son’s death, and all kinds of consequences that resulted from that death. Then we had to move 4 states away. My insurance company will not approve telephone or Skype sessions with my psychologist. They expect me to choose another therapist in my new state, but I do not want to start all over. If they would pay for a monthly therapy session, it would be a lot cheaper than having to spend so much time bringing a new doctor in on my case. I’d probably have to go once a week again for awhile, and go over material that my other doctor knows very well. The insurance company is dragging its feet on this, and yet anyone who reads medical articles can see that telehealth office visits are likely to be quite common in the future. These insurance companies haven’t joined the 21s century yet. All they have to do is figure out how to help the offices bill for it. My therapist and I decided that I can “blog” to him, writing emails periodically to keep him up to date, so that if /when tele therapy sessions are approved, he’ll be caught up on what’s happening in my life. I just cannot fathom the thinking here; why wouldn’t they trust him to treat me by phone, if they trusted him to treat me in the office?
    I’m sure there are much more serious instances of insurance company meddling. I understand the need to be watchful, but taking so many decisions out of doctor’s hands does not seem like a good outcome at all. These companies do not KNOW the patients like the doctors do. It would be so much better if insurance companies would trust the good doctors who care for us. Are their exceptions, doctors who prescribe something not necessary? Surely, but it seems to me that these would not be that common and would stick out as something way outside the norm. The insurance companies get their “norms” set and expect all patients to fit them. All patients do not.

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