{"id":4813,"date":"2007-05-08T12:21:31","date_gmt":"2007-05-08T19:21:31","guid":{"rendered":"http:\/\/oralcancernews.org\/wp\/?p=4813"},"modified":"2009-04-15T12:21:54","modified_gmt":"2009-04-15T19:21:54","slug":"implacable-insurer-only-adds-to-ordeal","status":"publish","type":"post","link":"https:\/\/oralcancernews.org\/wp\/implacable-insurer-only-adds-to-ordeal\/","title":{"rendered":"Implacable insurer only adds to ordeal"},"content":{"rendered":"<ul class=\"bullets\">\n<li><strong>5\/8\/2007<\/strong><\/li>\n<li><strong>Kansas City, MO<\/strong><\/li>\n<li><strong>Mike Hendricks<\/strong><\/li>\n<li><strong>KansasCity.com<\/strong><\/li>\n<\/ul>\n<p>Fighting the disease is only half the battle, Mary Casey says. That still leaves the insurance company.<\/p>\n<p>At least that\u2019s how it seems to the 57-year-old Brookside woman, a part-time admissions officer at St. Teresa\u2019s Academy. It\u2019s bad enough Casey had the misfortune of getting cancer. Now she finds herself on the wrong end of someone\u2019s cost-benefit analysis.<\/p>\n<p>\u201cI was stunned,\u201d she told me. \u201cI turned to my husband and said, \u2018Now what?\u2019\u2002\u201d<\/p>\n<p>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\u2019s effectiveness.<\/p>\n<p>\u201cYou can work all your life,\u201d Casey says, \u201calways pay your premiums, and then be blindsided by denial of coverage when the crisis hits.\u201d<\/p>\n<p>There is no news in that.<\/p>\n<p>Yet if we are ever to change the system, stories such as Casey\u2019s need telling. They remind us that all too often life or death comes down to dollars and cents.<\/p>\n<p>In this case, pills that cost about $3,600 for a month\u2019s supply.<\/p>\n<p>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.<\/p>\n<p>It did the following year, in the lungs.<\/p>\n<p>But there was hope, Casey\u2019s 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.<\/p>\n<p>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.<\/p>\n<p>Casey\u2019s physician, Chao Huang, asked Coventry to reconsider, as \u201cthere are few options for treating my patient and Tarceva offers the best opportunity for prolonging survival.\u201d<\/p>\n<p>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:<\/p>\n<p>\u201cThe 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.\u201d<\/p>\n<p>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\u2019s approved only for certain forms of lung cancer and cancer of the pancreas.<\/p>\n<p>In answer to my inquiries, the company issued a statement, which said in part: \u201cAt 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.\u201d<\/p>\n<p>\u201cClinically proven\u201d are the key words, because more than 20 studies are now investigating the drug\u2019s use for head and neck cancer, according to a spokeswoman for the manufacturer, Genentech. Early results are encouraging.<\/p>\n<p>Angie Schacher reports that her cancer has been stable since she went on the drug. She\u2019s 36, lives in Olathe and her disease is virtually identical to Casey\u2019s. They even share the same doctor.<\/p>\n<p>What they do not have in common is their insurance company. Schacher has Aetna, and Aetna\u2019s paying her claim.<\/p>\n<p>\u201cI don\u2019t want my obituary to read, \u2018She lost her valiant battle with the insurance company,\u2019\u2002\u201d Casey says.<\/p>\n<p>And battle she will. Having exhausted Coventry\u2019s internal appeals process, Casey\u2019s case is now under review by the Missouri Department of Insurance.<\/p>\n<p>Officials there will investigate whether Coventry is within its rights in denying the claims. Then an independent review board will take up the case.<\/p>\n<p>Coventry advised Casey that she also had the right to sue. However, it may never come to that.<\/p>\n<p>\u201cSometimes just because we ask, they\u2019ll pay,\u201d says department spokeswoman Emily Kampeter.<\/p>\n<p>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.<\/p>\n<p>Whatever happens, I\u2019ll let you know how it turns out. After all, what happened to Mary Casey could happen to any of us.<\/p>\n","protected":false},"excerpt":{"rendered":"<p>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\u2019s how it seems to the 57-year-old Brookside woman, a part-time admissions officer at St. Teresa\u2019s Academy. It\u2019s bad enough Casey had the misfortune of getting cancer. Now she finds herself on the wrong end of someone\u2019s cost-benefit analysis. \u201cI was stunned,\u201d she told me. \u201cI turned to my husband and said, \u2018Now what?\u2019\u2002\u201d 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\u2019s effectiveness. \u201cYou can work all your life,\u201d Casey says, \u201calways pay your premiums, and then be blindsided by denial of coverage when the crisis hits.\u201d There is no news in that. Yet if we are ever to change the system, stories such as Casey\u2019s 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\u2019s 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  [&#8230;]<\/p>\n","protected":false},"author":41,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"footnotes":""},"categories":[787],"tags":[],"class_list":["post-4813","post","type-post","status-publish","format-standard","hentry","category-oral-cancer-news-archive"],"_links":{"self":[{"href":"https:\/\/oralcancernews.org\/wp\/wp-json\/wp\/v2\/posts\/4813","targetHints":{"allow":["GET"]}}],"collection":[{"href":"https:\/\/oralcancernews.org\/wp\/wp-json\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/oralcancernews.org\/wp\/wp-json\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/oralcancernews.org\/wp\/wp-json\/wp\/v2\/users\/41"}],"replies":[{"embeddable":true,"href":"https:\/\/oralcancernews.org\/wp\/wp-json\/wp\/v2\/comments?post=4813"}],"version-history":[{"count":1,"href":"https:\/\/oralcancernews.org\/wp\/wp-json\/wp\/v2\/posts\/4813\/revisions"}],"predecessor-version":[{"id":4814,"href":"https:\/\/oralcancernews.org\/wp\/wp-json\/wp\/v2\/posts\/4813\/revisions\/4814"}],"wp:attachment":[{"href":"https:\/\/oralcancernews.org\/wp\/wp-json\/wp\/v2\/media?parent=4813"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/oralcancernews.org\/wp\/wp-json\/wp\/v2\/categories?post=4813"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/oralcancernews.org\/wp\/wp-json\/wp\/v2\/tags?post=4813"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}