Patient X was diagnosed with serious medical condition for which X’s doctor prescribed the most effective, safe medication. The medication, however, is unavailable in generic form and is expensive. Patient X’s insurance company denied coverage for the medication—not because the medication is “off-use” for the medical condition. In fact, the medication is among the only medications specifically for this condition. The insurance company denied coverage because other significantly less expensive medications also can be used to treat the condition, although the side effects of all the less expensive medications are worse in kind and *more dangerous* than any of those associated with the expensive medication. The patient’s insurance company indicates in their letter of denial that a formal appeal would have to be the next step.
Patient X figures that the appeal process is worth the effort. The worst thing that can happen is that the appeal is denied. The patient is already paying out of pocket for the superior medication, given the fantastic change in quality of life it has effected, and has completely given up eating out at restaurants to cover the cost, and plans to cancel cable TV and switch to Hulu when the time comes. The patient has never, until now, had a serious medical condition, and is pretty pissed-off that the insurance company had decided that more dangerous medications are better, despite the doctor’s insistence that they are not. It would be more fun, the patient finds, to appeal on principle. After paying five-figures to the insurance company over the years, it would seem they could handle a little extra paperwork coming their way. So much of that money paid to them affords the administrative salaries. Why not send them a little work?
The appeal process requires a doctor’s letter regarding the denied prescription. This is easy enough to get. But Patient X realizes that the Insurance company has not been impressed with all the test results and physician’s recommendation for treatment that were already sent with the initial request for coverage. Exactly what might improve this situation for an appeal?
Patient X decides to call the pharmaceutical company that produces the medication. X explains the situation, which is quite common, as it turns out, but representatives on the lower end are not sure what to do. Patient X freely (and sincerely) expresses the fact that their medication is fantastic, and that the insurance company is clearly denying coverage on account of expense and not the best interest of the patient. “What do you have about your medication—what data do you have? Surely, you must have evidence about its effectiveness that my doctor can use to draft the letter of appeal?” This question hits a homerun. X is passed along to a manager, and then passed along to the medical information team.
A member of the medical information team is more than happy to assist Patient X. It does not seem that the team gets enlisted in a crusade against an insurance company too often. They are unprepared for the request from a consumer for hard data, but after a bit of discussion clarifying the sort of data that would be helpful for this battle, a case file is created for Patient X, the direct line to the medical team member is provided, and X is told that the doctor can call to receive the available data the pharmaceutical company has. The medical information team promises to do whatever they can to win the appeal.
Patient X believes that it is best, all things considered, to let the Pharmaceutical Company and the Health Insurance company duke it out.