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The Dastardly Plans of the Unconscionable - 11/15/13

posted Nov 15, 2013, 3:47 PM by Kathryn Simpson
I wrote at the end of September that my insurance company had hung me out to dry regarding a possible new drug protocol to treat my delightful Multiple Sclerosis. You can read Hatin' the Haters - 09/29/13 to be dazzled by my wit. Here's an update. 

My neurologist filed an appeal. His appeal was denied. 

He filed another appeal, and requested a board-certified neurologist review my medical records to bear witness to the wisdom of the proposed new protocol. 

This appeal, too, was denied. The grounds? "Medical necessity."

So, the Insurance Company Paradigm (ICP) has determined that my chronic progressive illness doesn't make me sick enough to justify the care recommended by a medical professional. 

The first denied appeal left me devastated. For the 2nd one I only teared up briefly, and then I had to laugh. Because surely they can't be serious! But oh yes. Just like Leslie Nielsen, they are serious.

My neuro works closely with the company that produces this drug, and was closely involved with the trials when it was first launched a few years ago. Their combined response to the ICP response was to see if I'm eligible for a patient assistance program. Similar to a grant for students, it's intended to ease the financial burden for patients that either have no insurance or who's insurance doesn't cover much or any of the cost. 

Husband and I agreed to give this a shot, and received a response after only 2 business days. I was approved and would be able to start the new drug once the prescription is filled and I schedule an appointment with a hospital for observation of my first dose (Bitter note to ICP...People without "medical necessity" don't have to be placed under hospital observation for hours upon dose of a medication!). So...you know...forward motion! I am genuinely grateful for this news, and for the kind humans at the Pharma company who approved my request.

I haven't received the new Rx just yet, and therefore haven't scheduled my trip to the hospital so I can get started. But all of this has given me new insight into the ICP's decisions to deny my doctor's recommendation. Many Pharma companies have developed patient assistance programs. Certainly the ICPs are aware of such things, seeing as how they're all in bed together in the first place. So why approve a costly prescription for a patient when the patient, back against a wall, will HAVE to turn to the drug company for help meeting the financial burden? Stall the patient's care, deny doctors' requests and eventually someone will get desperate enough to humble themselves and throw themselves at the mercy of the drug maker. No need for the insurance company to be concerned at all, when the drug provider can share with me the burden of my fate. 


I've murmured this theory to some folks who are living with the same condition. They haven't yet told me if they think I'm nuts. Speaking of, I wonder if being "nuts" would meet the qualifications of "medical necessity" ? 

I think it's a safe bet the answer is no. 
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