Dr. Eric Shaw felt huge relief when he finally found a drug that stopped the allergic reaction that made it hard for him to swallow — and a significant blow when he learned his insurance company might not cover it.
Shaw, a pediatrician in Littleton, has dealt with insurance denials when trying to get drugs approved for his patients, but said Excellus BlueCross BlueShield's delay in paying for his own treatment for eosinophilic esophagitis used a new tactic. The company refused to pay unless he got an endoscopy procedure examining his esophagus to check for a placebo effect, which is essentially unheard of, he said.
The medication, called Dupixent, costs about $52,000 a year, and also has helped with his asthma, Shaw said.
"My worry is this is just a means to deny me the medication," he said. "To feel this helpless as a patient, even knowing how to navigate the system, has been a gut punch."
State and federal law gives insurance companies latitude to assess whether a drug or procedure is necessary before agreeing to pay for it, a process known as prior authorization. The idea is that insurers will flag wasteful and harmful treatments, and encourage patients to try out less-expensive options first.
Doctors and patients have raised concerns about whether some companies are putting up unnecessary hurdles or rejecting claims out of hand, though. A congressional committee is investigating insurance giant Cigna after reports its doctors were spending an average of 1.2 seconds reviewing cases before denying care as not medically necessary. Officials with the U.S. Department of Labor, which regulates most employer-sponsored insurance plans, said they also intend to take a look.
It's difficult to say whether insurance companies are truly getting stricter in deciding which medications they will pay for, or if doctors and patients are simply noticing it more and drawing greater attention to the issue. A survey of doctors by the American Medical Association found about 33% said they knew of a case where a patient's health deteriorated while waiting for prior authorization, and 64% said at least some patients had to first try a treatment that didn't work for them.
In Shaw's case, Joy Auch, a spokeswoman for Excellus BlueCross BlueShield, said she couldn't discuss any individual patient, but policies are based on current medical evidence. An independent committee of doctors and pharmacists also reviews the policies, and determined it was appropriate to require an endoscopy to confirm the drug's effectiveness, she said.
"This is to ensure the therapies we cover for our members are safe, effective and evidence-based," she said in a statement. "If a member has a concern about a coverage decision, we always encourage them to take advantage of their rights to appeal."
Prior authorization
David Allen, a spokesman for America's Health Insurance Plans, said prior authorization is one way companies protect their customers from receiving care that isn't safe or hasn't been shown to work. Insurers have taken steps to speed it up, like moving to electronic processing and "gold carding," where physicians with a track record of appropriate prescribing can skip some prior authorizations, he said.
"Patients deserve the most effective, safest and most affordable care. That's what prior authorization helps deliver," he said in a statement. "Independent studies show — and doctors agree — that differences in how care is provided to patients can lead to inappropriate, unnecessary and more costly medical treatments that can harm patients."
Dr. Patrick Pevoto, president of the Colorado Medical Society, said he understands the need for some checks on prescribing, since not all doctors have good intentions. But as is, the demands of prior authorizations add costs to the system, because practices have to hire someone to manage the paperwork, and long delays sometimes lead patients to stop trying to get necessary treatment, he said.
In the previous two legislative sessions, the Colorado Medical Society tried to get the state to set up a gold card program to streamline the prior authorization process, while still providing some oversight, Pevoto said. The group is collecting patients' stories to try to build support for a future push, he said.
"If the majority of doctors are doing the right thing, let it happen," he said. "Let patients get the care they need."
Shaw said he believes insurers loosened up during the pandemic, when they weren't spending as much on non-emergency care, and have clamped down as patients started getting procedures they put off. Sometimes, insurance companies decide they won't pay for a medication even if a patient has been stable on it for some time, and doctors have to make a best guess on what they'll approve when writing a new prescription, he said.
"The insurance companies are dictating to me and my patients," he said.
"Not medically necessary"
Sometimes, however, a denial that seems absurd to the patient can make sense later.
Robin Mulroney, of Highlands Ranch, said Bright HealthCare initially approved deep brain stimulation surgery to control tremors in her face and hands. She had the first part of the surgery in January 2022, to place electrodes in her brain. When it was time for the second procedure to place a battery in her chest and connect the wires, however, her insurance company said it was "not medically necessary."
"They knew from the very beginning" that it was a two-part surgery, she said. "Why would they approve for me to have leads put in my brain but not the batteries to make it all work?"
Bright HealthCare denied her initial appeal, but reversed itself less than 12 hours before the second surgery was scheduled. Mulroney thinks her advocacy on social media swayed them. The company, which has stopped selling individual and family plans, didn't answer questions about Mulroney's situation.
About a year later, though, Mulroney found out that part of the reason her insurance company had denied the second part of her procedure was that her doctors hadn't had her try less-invasive options. They also didn't conduct a thorough assessment of her tremors, which might have uncovered that she experiences two types, one of which isn't helped by deep brain stimulation, she said.
Now, she's going to try physical therapy and medication to see if they help with her left-side tremors, which didn't improve even as her right side did.
Mulroney said she still thinks her insurance company handled it in an unnecessarily stressful way, but she's no longer as confident that her doctors were entirely in the right.
"Possibly some of the flags that the insurance company raised were legitimate," she said.
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