Insurance company denies treatment for a 5 year old

guyver01

Lifer
Sep 25, 2000
22,151
5
61
The therapy is not approved by the Food and Drug Administration, and is considered "experimental" ... what insurance company covers "experimental" procedures?

At least off the bat, and without a fight?

i dont know of any.
 

ReggieDunlap

Senior member
Aug 25, 2009
516
49
91
The therapy is not approved by the Food and Drug Administration, and is considered "experimental" ... what insurance company covers "experimental" procedures?

At least off the bat, and without a fight?

i dont know of any.

The article mentions how the percentages of children who actually LIVE long enough to be considered for this treatment are so low kind of keeps it in the "experimental" category.

From the article.
"......"It's considered experimental because not enough kids with recurring neuroblastoma live long enough" to become candidates for MIBG, says Paul VanNocker, 44, a heavy-industrial-equipment salesman (Maria, 37, is a homemaker). "So, really, all treatment at this stage of Kyler's disease is considered experimental."

Only about 650 children in the United States are diagnosed each year with neuroblastoma. Half of them, including Kyler, have the most lethal form of the disease. So it's tough to study a large enough cohort of patients like Kyler to yield research results that HealthAmerica might consider valid.

But that doesn't mean MIBG is ineffective.

"It's considered the standard of care in Europe and the United States for recurrent neuroblastoma," says Grupp. "It's not an unproven treatment with no basis in medical science. Actually, the results are often very good." "

The low numbers of diagnosis probably impact the ability to provide enough "study data" to get the treatment approved.
 

guyver01

Lifer
Sep 25, 2000
22,151
5
61
The article mentions how the percentages of children who actually LIVE long enough to be considered for this treatment are so low kind of keeps it in the "experimental" category.

Insurance companies have covered "experimental treatments" ... but not immediately, and not right away.

It's usually a very long battle with the insurance company getting them to go thru arbitration and stuff.

It's probably an automated system that automatically rejected it because it's not FDA Approved & it's experimental.

Now they have to fight the insurance company and prove their case.
 

DivideBYZero

Lifer
May 18, 2001
24,117
2
0
So, insurance = Rules, UHC = Death Panel. Is that right? Just sorting out some of the terminology. I'm new to paranoid positioning, unlike most of you.
 

EarthwormJim

Diamond Member
Oct 15, 2003
3,239
0
76
Hmm, sounds like the FDA and the insurance company are acting like a "death panel" to me.

No one is acting like a death panel, the parents still could out right pay for the treatment.

Maybe with a loan, but oh wait if the loan is denied I guess the bank or lender would be a "death panel" too.
 

guyver01

Lifer
Sep 25, 2000
22,151
5
61
which explains why in the US you have health insurance, not health care.

I prefer the term.. Health Poker.

You're betting you get sick.
The insurance company (house) is betting you dont.

9/10 times.. when you get sick.. you still lose, the insurance company (house) still wins.
 

waggy

No Lifer
Dec 14, 2000
68,145
10
81
before people start bashing the insurance agency read the article and not just the OP's topic.

Unbelievably, Kyler's insurance carrier, Harrisburg-based HealthAmerica, has denied coverage for the treatment, which it considers "investigational/experimental" because there is "inadequate evidence in the peer-reviewed published clinical literature regarding its effectiveness."

The therapy is not approved by the Food and Drug Administration, another criterion that HealthAmerica require


It is not covered by the FDA. NO insuarance is going to cover it and if you think that once the goverment gets to insure people they will cover it you are sadly mistaken.

but still a sad story.
 

TruePaige

Diamond Member
Oct 22, 2006
9,878
2
0
I'll have to dig around to find a good link, but some of you people who think UHC wouldn't cover an experimental drug are wearing blinders.

NPR did a series on health care systems around the world and I don't know if you have to view the series to see the full info but here:

http://www.npr.org/templates/story/story.php?storyId=92136549

On the left in "Series At A glance" they talk about French health care being some of the best in the world and how they pay for experimental drugs.

France's fabled maternal care system and the country's new approach to treating cancer are the focus of Joseph Shapiro's stories.

"People feel secure that they'll get the care they need," he says, "even the most expensive, experimental drugs. And they know they won't have to fight constant battles with insurers to get coverage or manage their care."
 

Papagayo

Platinum Member
Jul 28, 2003
2,302
22
81
This kind of story pisses me off to no end.....my son will be five in a few weeks and I cannot even begin to imagine the pain....

http://www.philly.com/dailynews/loc...__The_insurance_company_vs__Kyler_s_life.html

I can understand the anger, but I don't think you should be angry or blame the insurance company. I also have a 6 year old kid.

The kid on the article has been sick most of his life. It also says that he's been at a hospital for 7 months at one time. With the chronic sickness, I am assuming that the insurance company probably paid quite a bit for the child.

Try to understand both sides..

If you want to blame someone, go to church and blame GOD..
Tell him to suck it..
 

TruePaige

Diamond Member
Oct 22, 2006
9,878
2
0
On a sad note that isn't quite related to health insurance but instead more directed towards health care..

It's not even like our systems failures are recent, in 1989 Canada had programs to help their doctors get AIDS patients life saving experimental drugs because doctors wouldn't dole them out in America.

To use the Canadian system, American patients would have to have the help of Canadian doctors and might have to go to Canada for some of their medical care. But for the first time the Canadian system would allow patients access to drugs that have not been marketed anywhere, as long as the drug company will sell them.

http://www.nytimes.com/1989/02/26/u...sick-americans-obtain-experimental-drugs.html
 

glenn beck

Platinum Member
Oct 6, 2004
2,381
0
0
I'll have to dig around to find a good link, but some of you people who think UHC wouldn't cover an experimental drug are wearing blinders.

NPR did a series on health care systems around the world and I don't know if you have to view the series to see the full info but here:

http://www.npr.org/templates/story/story.php?storyId=92136549

On the left in "Series At A glance" they talk about French health care being some of the best in the world and how they pay for experimental drugs.

http://news.bbc.co.uk/2/hi/europe/3423159.stm
if they can afford to keep on doing it
 

Beev

Diamond Member
Apr 20, 2006
7,775
0
0
Very sad, but rules are rules and the insurance company is just following theirs. Though I wonder if they saw the new Saw movie :p
 

techs

Lifer
Sep 26, 2000
28,561
4
0
before people start bashing the insurance agency read the article and not just the OP's topic.

Unbelievably, Kyler's insurance carrier, Harrisburg-based HealthAmerica, has denied coverage for the treatment, which it considers "investigational/experimental" because there is "inadequate evidence in the peer-reviewed published clinical literature regarding its effectiveness."

The therapy is not approved by the Food and Drug Administration, another criterion that HealthAmerica require


It is not covered by the FDA. NO insuarance is going to cover it and if you think that once the goverment gets to insure people they will cover it you are sadly mistaken.

but still a sad story.
100 percent WRONG!
Many procedures and treatments are not approved by the FDA despite being used for years. The FDA is not just slow to approve them, they often wait as long as ten years or more to collect data on the long term outcomes before even beginning to investigate it's effectiveness.
And the part that says "inadequate evidence in the peer-reviewed published clinical literature regarding its effectiveness." is the key part.

With FDA approval being pretty much worthless because of the many, many years they take to study the long term effects of treatment the "peer review" process is very, very important. And the "judgement" call of the insurance company is at question here. Often insurance companies still deny treatment despite overwhelmingly positive "peer review". And the problem is the insurance companies are pretty much just concerned with the cost and publicity and not the efficacy of treatment.

The good thing about a public option health plan would be that instead of the decision to cover a treatment being made by the health insurance company in secret, and with cost the overriding factor, decisions will be made in the public domain with the criteria being medical effectiveness.

As you know from my previous posts I was management at a large health care provider and actually participated in discussions on what procedures to cover.