Insurer Reverses Pre-approval For Cancer Drug
By Consumers for Quality Care, on August 10, 2018
As soon as Michele Brough was diagnosed with Stage 3 breast cancer, her doctors wanted move forward with treatment. Brough’s oncologist quickly reached out to her insurance company, Anthem Blue Cross Blue Shield, to apply for pre-approval for a drug to strengthen her immune system as she underwent chemotherapy. Los Angeles Times reports that Brough received pre-approval, only to be later denied.
Brough began chemo two months after her diagnosis. Her treatments included a shot of the pre-approved drug, Neulasta Onpro. But after Brough’s second round of chemotherapy, her oncologist said that her insurer would not be covering the drug after all.
As if that weren’t devastating enough, Anthem’s reasoning was downright absurd.
Yes, the drug had been pre-approved, but only if Brough bought it herself through the online pharmacy Express Scripts, and only if she gave herself the shots.
However, Brough’s doctor rejected the idea of self-injections.
And even if Indianapolis resident Brough had bought the drug, her husband said the oncologist refused for legal and safety reasons to administer a drug she had acquired herself.
Darrel Brough, who handled dealing with the bills and insurance for his wife, said that they decision made no sense to them. The rest of Brough’s treatment was covered.
[N]o reasonable person would anticipate a patient receiving chemotherapy treatments from doctors and nurses would be personally responsible for administering her own immune-system booster shots.
By the time the Brough learned that the shots would only be covered under certain circumstances, Michele had already received them twice.
Moreover, once the chemo has begun, you’re committed. Even though Brough and his wife were $14,000 in the hole after the second session, they weren’t going to stop even when the oncologist made Michele sign a waiver before the third round promising that she’d be responsible for the cost.
By the third round, they were facing a $21,000 bill for the injections. Brough’s oncologist decided to skip the shot, during the 4th round of chemo, hoping that her immune system would be strong enough on its own – and saving the couple an additional cost. Brough was told that if they didn’t pay the bill, it would be referred to a debt collector.
Los Angeles Times reporter David Lazarus expressed amazement at Anthem’s decision:
I’ve come across some strange insurance denials, often involving treatments that corporate bean counters say are experimental whereas actual medical professionals say otherwise. But Anthem took this up a level.
The company’s behavior seemed inconsiderate to the point of cruelty — at best an act of gross incompetence, at worst sheer meanness.
Once the Times got involved, Anthem reversed its decision.
It goes without saying, however, that no one should have to rely on the press to resolve an insurance matter — especially when the insurance company is at fault.
