>>insisting that she should be put on a different medication that has never so much as been studied, much less approved for treating MS.
I find this hard to believe and would be very interested in seeing details.
Ironically, Cigna has a very good speciality Rx program for MS.
>>I cannot fathom however why we as US citizens allow this cruel practice of private industry insurance to continue.
Did she find a Country where she was comfortable getting the denied treatment? What do you recommend besides "Government paying for everything"? What makes you think that "Medicare for all or whatever" will get the declined drug approved? Do you realize Canadians commonly get denied for things too? God forbid you have Rectal Cancer in Germany, generally not covered by the Government plan.
Pepto bismal is cheap, but we don't try treating a lung cancer with it just because of that. Again the drug they wanted her taking had NEVER been so much as studied for treating MS, and she had already exhausted a number of cheaper treatments including diet, PT and a number of other drugs, and a couple clinical trials. It's not like they jumped to the most expensive option. As for a second opinion, she is working with the only neurologist in the area who specializes in MS. Even if she wasn't I'm not sure why you think a second neurologist saying the same thing would change anything.
> Did she find a Country where she was comfortable getting the denied treatment?
No, no one researched hypotheticals. It's not like she can travel to another country and get treated under their healthcare plan. These generally only cover citizens and even if not she will need treatment for the rest of her life. This isn't a one time surgery where it might be cheaper to go to another country, then come home.
> What do you recommend besides "Government paying for everything"?
Well I do recommend single payer, because I'm of the radical mind that even the poor and unemployed deserve health care, but if that's off the table how about some actual oversight? We have an insurance company overriding a doctor who specializes in this disease insisting on a treatment that has NEVER been studied for this disease. This should not be legal. And yet the only recourse is to ask the same insurance company who already made this bad decision if they'd pretty please reconsider, or to find out if you can afford to pay lawyers for longer than they can. Maybe we should have an independent board one can appeal to. Make the consequences for incorrectly denying treatment dire. Like take away their license to operate if it happens to frequently dire. For many people delays can have serious consequences including death, if we are going to let these companies make such important decisions they should be held to a very high standard.
> Do you realize Canadians commonly get denied for things too?
Sure. Government can be fucked. Call me an optimist however, but I have a lot more confidence in my ability to drive meaningful change in my government than within Blue Cross.
> God forbid you have Rectal Cancer in Germany, generally not covered by the Government plan.
Does it not? Booking health (the Link you provided) appears to be a site for finding the best specialists around the world. The fact that it has a price list just implies to me that it has a cost for non German citizens. The article below the list even talks about getting "your cancer treatment in Germany for lower cost" which implies to me it's aimed at non-german residents. You may be correct, but I was not able to find any sources corroborating your claim with a quick search. Even if so, again as broken as government can be, I have a lot more say there than a private insurance company.
>>Pepto bismal is cheap, but we don't try treating a lung cancer with it just because of that.
What? I'm sorry that is not a reasonable statement. I have no idea what point you are trying to make.
>>Again the drug they wanted her taking had NEVER been so much as studied for treating MS
Again, without specifics I find that extremely difficult to believe.
>> because I'm of the radical mind that even the poor and unemployed deserve health care
I believe you are confusing administrators and payors. Even wealthy families get subsidized health insurance on the Marketplace. Medicaid is nearly free and medicare is for over 65 individuals. Do you know who administers Medicaid and Medicare?
>>This should not be legal.
It isn't which is why I'm having a difficult time believing your story.
>>Blue Cross
Which Blue Cross? What is the plan design? Was it employer based? What is the PBM?
>>appears to be a site for finding the best specialists around the world.
And yet that has nothing to do with the fact that healthcare is not free in Germany, and not single payer either, contrary to what 'radicals' like to claim.
>>I have a lot more say there than a private insurance company.
>> Pepto bismal is cheap, but we don't try treating a lung cancer with it just because of that.
> What? I'm sorry that is not a reasonable statement. I have no idea what point you are trying to make.
You stated that the insurance insisting on a non-related drug was step therapy, which is where one explores cheaper and less invasive treatments before exploring more expensive/invasive options. The point was step therapy does not include exploring treatment that there is no reasonable expectation will help.
> Again, without specifics I find that extremely difficult to believe.
I'm sorry. I'm not going to make my sister send me the drug names for a random internet discussion, and given the names of these things I unsurprisingly don't remember them. If you think I'm lying so be it, frankly I don't see how knowing the specific drugs involved would make that less likely.
FWIW it was a Parkinson's drug they wanted her to take, which might seem like it makes sense given the similarities between the diseases symptoms, but only if one doesn't understand the difference in cause and progression.
>> This should not be legal.
> It isn't which is why I'm having a difficult time believing your story.
The fact that you have a hard time believing that an insurance company might illegally deny a drug feels pretty shocking to me. The lawyer essentially agreed, it's probably not legal, but advised that fighting it would be extremely expensive and the best case outcome would be that she gets the drug, but it's more likely she runs out of money long before then. There are essentially no consequences when insurance companies do this, so of course they do. The worst case for them is they have to pay for the treatment eventually and most of the time it saves money.
> And yet that has nothing to do with the fact that healthcare is not free in Germany, and not single payer either, contrary to what 'radicals' like to claim.
I made no claim about Germany. I have no idea why you brought it up. I thought you were pointing out flaws in single payer systems, but now you tell me it isn't single payer?
>> I have a lot more say there than a private insurance company.
> Specifically, how so?
Voting, writing my senator/congressman, etc. Our government is broken in a lot of ways but are you really asserting we have zero influence? Because that's what I have with private companies.
>>The fact that you have a hard time believing that an insurance company might illegally deny a drug
No, I find it hard to believe, as you alluded to, Blue Cross were trying to get her on the equivalent of pepto for cancer. A Parkinson's drug likely has a correlation and is hardly pepto which is over the counter. Sounds like you acknowledge that even...
>>Voting, writing my senator/congressman, etc. Our government is broken in a lot of ways but are you really asserting we have zero influence? Because that's what I have with private companies.
You want to get an insurance company to respond quickly? Each State has an insurance commission with a phone line, email etc. I wish you the best of luck with Congress.
>>insisting that she should be put on a different medication that has never so much as been studied, much less approved for treating MS.
I find this hard to believe and would be very interested in seeing details.
Ironically, Cigna has a very good speciality Rx program for MS.
>>I cannot fathom however why we as US citizens allow this cruel practice of private industry insurance to continue.
Did she find a Country where she was comfortable getting the denied treatment? What do you recommend besides "Government paying for everything"? What makes you think that "Medicare for all or whatever" will get the declined drug approved? Do you realize Canadians commonly get denied for things too? God forbid you have Rectal Cancer in Germany, generally not covered by the Government plan.
https://bookinghealth.com/disease/colorectal-cancer/germany