[Harrison]

Not enough scientific proof?

How many of you have had a treatment denied, written an extensive appeal, then lost -- only to be told, "There is not enough long-term scientific proof"?

Insurers love this reason for denial. They love it so much, that they often say it, even when it is not true. It sounds so factual, so fair, so indisputable.

I have never lost an appeal for "not enough scientific proof." And I do not want any of you to ever lose an appeal for this reason.

There are many ways to overcome this objection. Let's talk about one of them ...

Evidence-based medicine?

When your insurance company is being ridiculous, you need first to recognize it, and then point it out in your appeal.

In 2009, I took on the case of Amy from Colorado. She had an advanced case of ovarian cancer, which had spread throughout the abdomen. For several years, her local doctors had been treating her with repeated "debulkings," and systemic chemotherapy.

"Debulking" means "taking out the bulky tumors, and leaving the rest." What if you had breast cancer? Would it make sense to you to if the surgeon said, "We will take out the big tumors, and leave the rest"? Not the most effective approach.

Only problem is, it is much more difficult in every way to clean all visible tumors out of the abdomen than it is to remove all visible tumors out of the breast. There are surgeons who know how to do it. However, the are not usually local, and they are not often in-network.

Finally, after years of recurrences and more treatments, Amy happened to hear about the one definitive treatment for cancers which have spread throughout the abdomen -- cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). She wanted to get to the surgeon with the best documented long-term outcomes with this complex surgery and treatment.

All of Amy's available appeals had been denied. It was now my job to get the denials reversed, and the treatment approved.

Turnabout is fair play

When I write an appeal, I do my best to anticipate whatever arguments the insurance company is going to come up with. After winning sixty lifesaving appeals, this is fairly easy to do.

Insurance companies have paid for cytoreductive surgery and HIPEC hundreds if not thousands of times. Many of the insurers' medical policy statements endorse this treatment -- for appendix cancer. Not for ovarian cancer.

The standard treatment for ovarian cancer is repeated debulkings and systemic chemotherapy. If the patient is lucky, they may get IP chemotherapy along with the debulkings. This is what they do, doctors and insurance companies are very comfortable and attached to this treatment regimen -- regardless of how effective or ineffective it may be.

Wake-up moment: Just because a treatment is routinely offered in-network, doesn't mean that it is effective, the most effective, or scientifically proven.

I stayed up half the night, learning about ovarian cancer, the treatment of it, the scientific articles about it. I found the followin gold nugget, and I presented it in the appeal:

I quote from Peter Schwartz, MD, John Slade Ely Professor of Obstetrics, Gynecology, and Reproductive Sciences, Yale University School of Medicine:

"The standard management for previously untreated advanced-stage epithelial ovarian cancer is optimum surgical debulking followed by aggressive cytotoxic chemotherapy. This approach is based on a retrospective review of a single-institution experience published more than thirty years ago and has yet to be confirmed in a prospective randomized trial."
(Schwartz, PE. Cytoreductive surgery in the management of ovarian cancer. Oncology 2008; Vol 22:9.)

When I found this, I almost fell off my chair. The standard treatments that are offered all over the United States for ovarian cancer are based on one scientific article -- a retrospective study of patients at one institution, published more than thirty years ago. No randomized trial, no long-term outcomes.

The insurer is not offering "evidence-based medicine." It is rather embarrassing, when I point this out to them in an appeal.

The same is often true, regardless of the treatment. Need artificial disc replacement? They tell you there is "no scientific proof of long-term outcomes"? How much scientific proof do they have for the treatment that they do offer -- spinal fusion? Zero.

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Insurers need to be held to the same standards to which they hold us. You and I -- the patients who are denied -- are the only ones who are going to do it.

When we request a treatment that is either out-of-network, or more than fifty miles from our house, the insurer demands a level of proof that they would be hard-pressed to provide for the treatments that they ARE offering.

The emperor has no clothes.

When your insurer is being ridiculous, you need to recognize this, and point it out to them in your appeal.

Happy and peaceful Insurance Warrior-ing,

Laurie Todd