• 5/8/2007
  • Kansas City, MO
  • Mike Hendricks
  • KansasCity.com

Fighting the disease is only half the battle, Mary Casey says. That still leaves the insurance company.

At least that’s how it seems to the 57-year-old Brookside woman, a part-time admissions officer at St. Teresa’s Academy. It’s bad enough Casey had the misfortune of getting cancer. Now she finds herself on the wrong end of someone’s cost-benefit analysis.

“I was stunned,” she told me. “I turned to my husband and said, ‘Now what?’ ”

What floored Casey was that her oncologist prescribed one of the few drugs that work on her rare form of cancer. Yet her insurance company refuses to pay for the expensive new medicine, despite studies showing the drug’s effectiveness.

“You can work all your life,” Casey says, “always pay your premiums, and then be blindsided by denial of coverage when the crisis hits.”

There is no news in that.

Yet if we are ever to change the system, stories such as Casey’s need telling. They remind us that all too often life or death comes down to dollars and cents.

In this case, pills that cost about $3,600 for a month’s supply.

Casey was diagnosed with head and neck cancer in early 2005. To excise the malignant tissue, a surgeon at the KU Cancer Center removed the roof of her mouth and replaced it with a synthetic one. He prescribed a regimen of radiation treatments but warned that the cancer was likely to return somewhere else in the body.

It did the following year, in the lungs.

But there was hope, Casey’s regular oncologist said. Hers was a slow-growing cancer, and studies had shown that patients with the disease had success taking a drug called Tarceva.

Casey had hope until Coventry Health Care of Kansas Inc. denied coverage. Tarceva was not government-approved for use on nose and throat cancer, Coventry said, and therefore deemed experimental, which was not covered.

Casey’s physician, Chao Huang, asked Coventry to reconsider, as “there are few options for treating my patient and Tarceva offers the best opportunity for prolonging survival.”

But five days later, March 21, the insurer denied the request again with a bit of editorial comment that makes clear the roles played by health professionals and insurance companies in America today:

“The fact that a physician or health-care provider may prescribe, recommend, order, or approve a service or supply does not of itself determine medical necessity or make such a service of supply a covered benefit.”

To give Coventry its due, Tarceva has not been through all the trials necessary for Food and Drug Administration approval in the treatment of head and neck cancer. It’s approved only for certain forms of lung cancer and cancer of the pancreas.

In answer to my inquiries, the company issued a statement, which said in part: “At Coventry, decisions are made based upon clinically proven treatments. In those situations where a requested course of treatment has not been proven, approval may not be granted.”

“Clinically proven” are the key words, because more than 20 studies are now investigating the drug’s use for head and neck cancer, according to a spokeswoman for the manufacturer, Genentech. Early results are encouraging.

Angie Schacher reports that her cancer has been stable since she went on the drug. She’s 36, lives in Olathe and her disease is virtually identical to Casey’s. They even share the same doctor.

What they do not have in common is their insurance company. Schacher has Aetna, and Aetna’s paying her claim.

“I don’t want my obituary to read, ‘She lost her valiant battle with the insurance company,’ ” Casey says.

And battle she will. Having exhausted Coventry’s internal appeals process, Casey’s case is now under review by the Missouri Department of Insurance.

Officials there will investigate whether Coventry is within its rights in denying the claims. Then an independent review board will take up the case.

Coventry advised Casey that she also had the right to sue. However, it may never come to that.

“Sometimes just because we ask, they’ll pay,” says department spokeswoman Emily Kampeter.

Also, aid is sometimes available from drugmakers or one of the cancer societies. Casey checked, but she and her husband, Ben, a retired Kansas City police officer, earn too much to qualify, but not enough to absorb the cost of the drug without great hardship.

Whatever happens, I’ll let you know how it turns out. After all, what happened to Mary Casey could happen to any of us.