Coverage Denial

The click-bait title, Insurer allegedly sends coverage denial letter to 9-month-old with brain cancer, may make you think that the insurance company is evil, which they are, but this example may not be a great one:

The 9-month-old son of a retired NYPD officer allegedly received a letter from the family’s insurance company recently, explaining that the clinical trial he was enrolled in to treat aggressive brain cancer was “not medically necessary,” and therefore would not be covered by the provider.

“The principal investigator has requested medications including methotrexate, cisplatin, cyclophosphamide, vincristine in combination with an investigational medication, alisertib,” the alleged letter purportedly said.

“This combination of medications is not the standard of care for this type of cancer, and is considered experimental and investigational at this time, as evidence-based guidelines do not exist to confirm its effectiveness for his brain tumor. Therefore, this request for clinical trial treatment at St. Jude’s hospital is not medically necessary and is denied.”

So, here is the issue I am having with this.  We all want to jump on the “hate” bandwagon because we all know that the insurance companies just want to save money.  I get that and I really hate to defend them here but do YOU know if methotrexate, cisplatin, cyclophosphamide, vincristine in combination with alisertib works?  I don’t.  Should cancer doctors get carte blanche to pick whatever research combination drugs they want?  There has to be some checks and balances here.

How in the world can anyone think this country would be okay with rationing (socialized medicine) when we are not okay with it now?

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  4 comments for “Coverage Denial

  1. Dr Bonz
    October 23, 2017 at 7:38 am

    I think this entire article is false and made up as a vehicle of the anti-insurance company movement. Notice the buzz phrases in it? The father of the supposed sick child is a retired NYPD officer? And it of course contains the obligatory sad picture of a sick child in a hospital bed. Always good for a few thousand sympathetic clicks. It mentions a combination of drugs that looks like someone who has no idea about treating cancer made up by Googling “cancer drugs”. I’m not an oncologist but does anyone know if this combination of drugs has EVER been used in a 9 month old baby with brain cancer? They also had to use the name of a famous center that treats children and the only one the author of this article knew was St. Jude.
    Finally ,even if this really did involve St. Jude hospital, St. Jude most likely will accept payment if it is rendered, but if not, it does not charge the family. This appears to be a completely made up article.

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  2. Randy
    October 22, 2017 at 11:15 am

    I thought St. Jude’s was free as well, so I wasn’t sure what to make of that. Maybe they accept insurance payments when they can? My guess is that there will be expenses outside the alisertib that the parents would like covered.

    But Doug really speaks to a larger question – who is going to say no to medical care with little benefit and how will patients accept that? Seems like many people like the idea of a Canadian system without the cost-containment measures – well, that won’t work.

    And doctors are part of the problem. I’ve had patients that have seen multiple oncologists that didn’t know they had a metastatic cancer that was eventually going to kill them, and that all treatment was solely to extend and improve their life . It was left to me to tell them that. The oncologists were mainly looking toward the next round of treatment options. And that’s just a drop in the bucket of the rampant waste and over-utilization in US medicine.

    I read an article recently on KevinMD complaining about the insurance company peer-to-peer reviews. I hate them too, they’re a pain in the ass, but it has fallen to insurance companies to contain costs and I don’t see anyone else doing it.

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  3. Sir Lance-a-lot
    October 22, 2017 at 8:07 am

    Doug, I think the point is that investigational treatments are never covered – they are paid for by the study’s grant. Also, the insurance company denied payment to a hospital where all care is completely free, so it doesn’t really matter anyway.

    That, and a combination of cisplatin, cyclophosphamide, and vincristine, with or without any other meds, is essentially lethal no matter what, so it looks like this is a last-ditch, “throw everything at it at once” pre-terminal treatment and the poor kid doesn’t have a chance.

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    • Steve O'
      October 23, 2017 at 10:47 am

      I am not a pediatric oncologist but – interesting that CHOP, which is used for lymphomas, including CNS B-cell lymphomas, is the mainstay of treatment discussed here. We tend to think of “aggressive X cancer” as being one in which the primary arises in X. The lay public tends to attribute the location of the cancer with the name, e.g. “liver cancer” for mets.
      It looks poorly reported even if not completely false.

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