When Health Insurance Denies a Baby's Cancer Treatment

Yes.

So the mutation was targetable by a medication called lorlatinib.

And this was reviewed by a few different institutions.

Everyone agreed that lorlatinib is the best medication for her.

So then our doctor put in the request, put in the prior authorization.

We thought it would be a pretty clear cut case of Here's a mutation.

Here's a medication that has been shown to work.

And it minimizes the side effects of going in every inpatient once a month for a week at least to do IV chemo, which is much more devastating.

So then we hear back from the insurance.

They came back saying it's not medically necessary and it doesn't meet our criteria.

So therefore, we're going to deny it.

That was really upsetting to hear.

That probably took a week and a half.

I was calling in the meantime to ask, when would you have the results? And it took, you know, you kind of get thrown around to different people saying, okay, tomorrow, give us a call back tomorrow.

Tomorrow, give a call back.

You're talking to someone new to say, I don't know, give us a call back tomorrow.

And so that happened finally a week and a half of kind of almost daily calls.

We had heard that we got the first denial.

And so then our doctor put in an urgent appeal and sent in more papers supporting the use of this medication, sent in another long letter about why this is the right medication.

And so then Blue Cross took another look at all of that, and they again denied it, saying that it was medically unnecessary.

The other thing they said was that Zoe doesn't have metastases, and so therefore it's not needed at this time, and that was very frustrating.

So I had a conversation with them about, okay, who is reviewing this? Because if there was any neuro-oncologist who is well-versed in the pediatric brain tumor world, they would know that this is the right course of treatment.

This is the first course of treatment.

And they kept saying, well, we can't give you that information.

It was just our medical director, our medical director.