Insurance Denials Can Be Death Sentences

                  Molly Fetzer

Self-funded school district overrides TPA’s (Anthem) decision to deny coverage and authorizes doctor ordered treatment plan for stage 4 cancer member………………….

This article referred by Eric Dreyfus

Set up to fail: Insurance denials complicate woman’s cancer battle


PUBLISHED: FEB 6TH, 2019 – 2:34PM (EST)

UPDATED: FEB 8TH, 2019 – 10:34AM (EST)

HAMILTON COUNTY (WTHR) — A Stage 4 cancer patient is making serious claims about an insurance industry practice that she believes set her up to fail.

Molly Fetzer turned to 13 Investigates after discovering a policy that can keep patients nationwide from getting the most effective treatment when needed.

WTHR found insurance providers can deny doctors’ orders and force patients to try less effective or lower cost options first, as part of a practice called “step therapy.”

An entire dining room wall inside Molly Fetzer’s Hamilton County home is covered with well wishes. A uniquely inspired collection of cards, photos, drawings and letters all displayed as loving reminders of Molly’s army of supporters.

“When I’m not feeling well, I just kind of pause and think about all the people,” she said smiling as she re-read one of the notes from a friend.

Diagnosis and denial

In late November, the 37-year old mother of twin boys and special-ed teacher woke up with a numb jaw and flu-like symptoms. Within a matter of weeks Molly received a grim diagnosis.

“It was Stage 4 metastatic breast cancer,” said her father, Brian Fetzer, who was there when doctors broke the news.

“There are spots on my liver, my bones, my brain and my breasts,” explained Molly, who had no other symptoms that anything was wrong. Like many women under 40, she had never had a mammogram.

Molly’s team of doctors planned an aggressive attack. Her oncologist prescribed Eli Lilly’s new metastatic breast cancer drug Verzenio. Her doctor believed it was the most effective and appropriate choice for HR(+) her2(-) breast cancer. But Molly’s insurance administrator denied coverage for the drug, questioning the “medical necessity” for Verzenio.

In its denial letter, Anthem said Verzenio could be prescribed only after Molly had undergone monotherapy followed by endocrine therapy or prior chemotherapy. Bottom line, Anthem wanted Molly to go through a progression of treatments first.

“They want patients to go through what they call “step therapy” or “fail first therapy,” said her father. “That means take a form of treatment that isn’t the most current. You have to take that and then have that fail before we’ll pay for the newer FDA approved treatment,” he added.

Fighting for coverage

Groups all across the country are now pushing back against “step therapy.” Advocates warn patients are suffering while being forced to endure a series of ineffective treatments under the policy.

At least 20-states have passed legislation regarding the practice.

In 2016, Rep. Donna Schaibley (R) who represents parts of Boone and Hamilton Counties authored a bill to clear a way for patients to appeal the denial of prescription drugs under “step therapy.” The law requires insurers to provide a reason for the denial and sets up time limits for pre-authorization. But there are no law to address step-therapies and treatments in Indiana.

“When you’re in a situation like that, time is of the essence to get treatment that is appropriate for you,” Rep. Schaibley told 13 Investigates.

For Molly, a state law wouldn’t matter anyway because of her type of insurance.

Self-insured Plans

  • Employer pays each claim.
  • Employer assumes financial risk.
  • Employer can contract with third-party.
  • Third-party handles enrollment, claims, etc.
  • Regulated under federal law. State has no oversight.

Self-Insurance Institute of America

Her employer, Westfield Washington Schools, has a self-funded insurance program with no state oversight. It’s set up under federal ERISA guidelines that provides minimum standards for health plans in private industry.

The school district itself pays the cost of coverage, but contracts with a third-party insurance provider like Anthem to provide and administer plans and make medical determinations about what to pay and how much. Until she got sick, Molly never had a reason to question her coverage.

“You hope to not need it, but when you need it, it’s supposed to be there,” she told 13 Investigates.

Molly appealed Anthem’s denial for Verzenio.

At the same time, Anthem also denied a new radiation technique to target lesions on Molly’s brain that would significantly reduce the risk of severe memory loss. Once again, Anthem said the technique was “not medically necessary.” Anthem went on to say that the treatment could only be used “if you have had radiation in this area before.”

“It’s not right,” said Molly in disbelief.

Some doctors consider the memory sparing technique a new standard of care. It’s based on the results of a clinical trial that showed the new technique just as effective as traditional whole brain radiation but with improved learning and memory functions and fewer neurological symptoms for patients. The findings were presented last October to the American Society for Radiation Oncology.

What you can do

  • Ask your provider for detailed explanation for denial
  • File an appeal to the insurance provider
  • Ask your doctor to provide follow up information
  • File a complaint with the Indiana Department of Insurance (only if you are u traditional insurance program)
  • File a complaint with your Benefits Coordinator (if you are covered as part of a self-insured program)

“This study has shown definitively that we’re able to prevent those memory issues and treat these patients safely with the most effective treatment we have. It should be used on patients who have brain metastases,” said Dr. Vinai Gondi, the study’s co-investigator and Research Director at Northwestern Medicine Cancer Center in Chicago.

Molly’s father and Rep. Schaibley believe insurers are more focused on cutting the rising cost of health care.

In Molly’s case, the difference in cost is about $3,500 per treatment.

According to 2014 Medicare costs analysis, traditional whole brain radiation costs $6,500 per treatment.

The new memory sparing technique costs just under $10,000 per treatment.

Molly opted to move forward with the new treatment and continue to fight Anthem. At the end of it she owed $106,000 out of pocket.

“You can’t put a price on that,” she told 13 Investigates.

“Why expose them to a higher risk when there’s an equally effective treatment available? Just because it’s 25 percent or more expensive,” questioned Molly’s father. “To me that’s putting dollars over a patient’s health,” he said with disappointment.

Getting approval

Days after 13 Investigates questioned Anthem about its denials, the insurance company reversed it’s decision on Verzenio and approved coverage for it.

But Anthem would not budge on the memory-sparing technique and refused to provide further explanation.

“I can’t believe this. We’re going to have to go back and fight them,” said Molly recalling the frustration she felt after learning she had lost her expedited appeal.

13 Investigates made numerous attempts to get more information from Anthem on its policies regarding “step therapy.”

Statement from Anthem Blue Cross Blue Shield:

Anthem Blue Cross and Blue Shield wants to help consumers who face serious health challenges get access to covered medical treatments that have been shown by medical evidence to be effective. In this case, the question is what services qualify for coverage based on the individual’s specific benefit plan, her health circumstances, the clinical information provided to us by the treating physicians and nationally recognized care guidelines.

Two board-certified radiation oncologists reviewed this case against clinical guidelines from the American Society for Radiation Oncology. Based on the medical information we received, the requested treatment did not meet the criteria to be covered under her employer’s benefit plan. This decision does not prevent or advise against treatment; it is solely a covered benefits decision at this time.

The member filed an initial of appeal with Anthem, but declined to pursue the next levels of appeal.

The medication request (Verzenio) was then approved after Mrs. Fetzer’s physicians provided additional information.

After seven weeks of battling insurance and Stage 4 cancer, a bargaining unit at Westfield Washington Schools voted to override Anthem, it’s insurance administrator, and cover the cost of the memory-sparing technique for Molly as well.

Now for the first time since her diagnosis she can focus exclusively on her health.

Molly has been sharing her journey on Facebook with the hashtag #sweatformolly.

“I’m trusting, praying, having faith it’s going to work out the way it’s supposed to,” she said.