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3.30.2010

Discover Health Advocacy: Coverage denial for an experimental treatment

We built our company, Health Advocate, Inc., to help people navigate the complex healthcare system and to provide them answers when they need them the most. Here is an example of how we have helped a member with a healthcare solution.

Problem: Coverage denial for an experimental treatment

Jane was diagnosed with pheochromocytoma in 2004, a rare tumor of the adrenal gland that causes excessive release of epinephrine and norepinephrine – hormones that regulate heart rate and blood pressure. In 2005, Jane was treated with MIBG with success. Unfortunately, the cancer returned and spread to Jane’s other organs. This time, the second MIGB treatment was delayed because Jane’s insurance company determined that the drug used to pre-treat her cancer was experimental and, therefore, not covered. To complicate matters, the hospital’s attempts to get approval for the procedure from the insurance company were delayed until the insurance company received the required information to proceed with the review. The hospital sent the requested information but the review did not proceed. Time was running out for Jane and treatment became a life or death situation.

Solution:Health Advocate coordinated a conference call between the hospital and her insurance company and suggested that the hospital renegotiate their contract with the insurance provider for this particular treatment to prevent future issues. The insurance company finally approved the treatment for Jane and now covers the service for future treatments.