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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