Insurer Denies Man’s Painkillers After Back Surgery

By Consumers for Quality Care, on September 26, 2017

Insurer Denies Man’s Painkillers After Back Surgery

Joe Stanziano had recently undergone his fourth back surgery in five years, when his doctor prescribed an opioid to aid his recovery.  As recovery progressed, his doctor decided to start tapering off the pain meds by prescribing a lower dose.

Stanziano’s insurer denied coverage of the medication. PAMED recently reported Stanziano’s experience to highlight the consequences of insurer authorization denials for patients.

When the medicine ran out, the withdrawal symptoms began.

 “Cold sweats. Shaking. You don’t have control,” Stanziano said.

 This wasn’t a one-time mistake by his insurance company.

Stanziano’s doctor tried to prescribe the medication five times and each time it was denied by the insurer.

Insurance companies say they use prior authorization to prevent physicians from prescribing too much medication or ordering too many tests. But physicians say the use of prior auth has grown out of control[.]

When an insurer denies an authorization, there can be both physical and monetary consequences for patients. For Stanziano, the authorization denial meant that he had to pay for the medication out-of-pocket, to the tune of $60/pill.

Like many who face insurance denials, Stanziano and his doctor were frustrated by the lack of transparency and logic behind the decision.

“One could imagine a reason for (denying it) if we’re increasing the medication, but in Joe’s case, we were gradually decreasing the medication,” said Daniel Skubick, MD, Stanziano’s neurologist. “In spite of the fact that we were doing the right thing (by lowering his dosage) – getting him off opioids – pre-certs would still be coming.”

“You could talk to two different people (at the insurance company) in the same day and get two different answers,” he said. “Explain to me the logic – why are you denying it when we were trying to reduce (the medication)? Does it make sense to you?” 

A recent investigation from The New York Times and Pro Publica found that many insurers are also denying more expensive, safer opioid alternatives.

Only one-third of the people covered, for example, had any access to Butrans, a painkilling skin patch that contains a less-risky opioid, buprenorphine. And every drug plan that covered lidocaine patches, which are not addictive but cost more than other generic pain drugs, required that patients get prior approval for them.

Additionally, the Department of Health and Human Services has come to a similar conclusion.

The Department of Health and Human Services is studying whether insurance companies make opioids more accessible than other pain treatments. An early analysis suggests that they are placing fewer restrictions on opioids than on less addictive, non-opioid medications and non-drug treatments like physical therapy, said Christopher M. Jones, a senior policy official at the department.