General Rant regarding Prior-Authorization from Insurance companies

[Duaine]

Physician Fights Insurer to Cover Her Baby's Brain Cancer Treatment​

On June 9, 2023, Eunice Stallman, MD, a psychiatrist in Boise, Idaho, got some of the worst news of her life.

The worrisome symptoms she and her husband had been noticing in their 8-month old daughter for some time -- twitches in the right side of her body, trouble sitting up -- were due to brain cancer. After Zoey's doctors ran some tests, they discovered a large tumor spanning the left frontal, parietal, and temporal lobes of her brain. It had grown around a middle cerebral artery and its branch, making surgery nearly impossible without dire consequences.

But Stallman couldn't have predicted that her family's bad dream would turn into a uniquely American nightmare. What a team of doctors agreed was the best course of treatment for Zoey would be denied not just once, but three times by Stallman's insurance, delaying Zoey's care by weeks and plunging her family into a labyrinth of prior authorization submissions, insurance appeals, and medical reviews.

After a biopsy showed a very rare cancer -- infantile hemispheric glioma, ALK-altered subtype -- Zoey's doctors at St. Luke's Cancer Center in Idaho jumped into action. They consulted with a team at Seattle Children's Hospital, known for its pediatric brain tumor program. The MRI had shown an unusually large tumor, 9 × 5 × 6 cm in the left side of her brain and around the middle cerebral artery. Surgery near this major artery would bring with it a "significant risk of stroke and neurologic deficits," Zoey's doctor would later write in a letter to Stallman's insurer.

She pleaded with the Blue Cross representative, reviewing the insurance policy used for the denial with the caller line by line, making her case for the medical necessity of lorlatinib. She cited her daughter's molecular analysis showing that the tumor had a mutation -- ALK -- with high clinical significance.

The only option left would be a "peer-to-peer" meeting -- a phone call between Zoey's oncologist and another Blue Cross medical director to discuss the case. Stallman was still angry -- what were their credentials anyway, she asked?

The woman on the other line told her they were doctors of pharmacy.

Stallman remembered thinking, "Are you serious? Like, are you kidding me? So they're pharmacists who are not seeing Zoey directly. They don't have prescribing and treatment experience. ... And they're going against the recommendations of multiple doctors who are looking at her case."

But she felt hopeful that surely, after Zoey's doctor could explain the details of the case, any misunderstandings would be cleared up, the urgency of her condition would be conveyed, and her daughter could begin her care.

The medical director and Zoey's oncologist discussed her case for 45 minutes. But again, the insurers told her the answer was no.
[EXTERNAL LINK] - Physician Fights Insurer to Cover Her Baby's Brain Cancer Treatment

 

[STIBROKER]

Physician Fights Insurer to Cover Her Baby's Brain Cancer Treatment​

dang.....1 post away from the

1,000 Mile Club​

 

[ehall2]

Insurance companies don't need to tell doctors how to practice medicine. I have a granddaughter that has had problems with her tonsils all her life. She is now 21 and just had her tonsils removed. She has been in very bad pain since surgery. I asked why her tonsils weren't removed when she was a child and the doctor said, if she doesn't have a certain number of times she has problems with her tonsils the insurance company won't pay. I wonder how much more it cost the insurance company now than if she had her tonsils removed as a child.