I just read of a a jury award in excess of $25 million against an insurance company who denied a recommended cancer treatment to a patient who ultimately died.  I do not wish to review here the particulars of this case, and admit that my knowledge is limited by one news report that I read.  While I will not invoke the ubiquitous phrase “fake news,” I always bring some measure of skepticism to various news sources, even those who enjoy excellent reputations.

But this jury case raises an issue that physicians and patients wrestle with regularly.

The physician prescribes a medication or recommends a treatment.

The insurance company denies coverage for the recommendation.

Sometimes, the reason for the denial is entirely reasonable.  For example, if an insurance policy restricts a patient to a network of physicians, the company will deny coverage if the patient wants to seek care out of the network.  It would not be reasonable for a patient who had access to network cardiologists to expect that a visit with an out-of-network cardiologist would be covered.

Sometimes, the reason for a denial is absurd.  A physician prescribes a medication.  The insurance company denies coverage insisting that the medicine would be covered only if different medicines were tried first and were not effective.  The term for this is step therapy requirement and doctors despise it.  So, this is not a categorical denial, like with the cardiologist example above, but is a qualified denial.  The medicine is covered if the physician complies with insurance company edicts.  Here’s what the physician might tell his patient:

I prescribed a medication to you that my training and experience informs me is the best choice for you.  Instead, let’s spend the next few months giving you some different medicines, just for fun.  I don’t think this medicine really makes sense in your case; that’s why I didn’t prescribe it.  Your insurance company, who always has your health and welfare as its highest priority, want us to wander off course for a while.  Who knows?  Miracles happen.  Maybe the stuff might work by accident.  No need to fret too much.   Eventually, they will give in and you will ultimately get the right stuff covered.  And think of all the quality time the two of us will enjoy on our journey together!

Here are some of the effects of the qualified insurance company denial.

• It wastes money.
• It exposes patients to risks of side-effects from unnecessary medications.
• Physicians and their staffs get to fill out lots of fun forms filled with ridiculous documentation requirements.  This is a welcome distraction for our staffs from the stress of their typical office responsibilities.
• Some patients and physicians simply give up.  Do you think this might be one of the unstated goals of Big Insurance?
• It delays the right medical treatment.
• It pisses off patients.
• It pisses off doctors.
• It reinforces the narrative that insurance companies are self-serving corporate entities whose overriding mi$$ion is profit.

There are also many occasions when a denial is neither clearly reasonable nor unreasonable.  It can be difficult to determine if a recommended treatment is standard or experimental, especially if experts disagree on this point.  This is not a major issue if one is considering a treatment for acne.  But, what if an oncologist recommends a bone marrow transplant (BMT) for a desperately ill person, which some experts and institutions regard as experimental?   Does it matter if the FDA has not approved the treatment?  What if other countries have decided that a BMT in the same circumstance is standard treatment?

These scenarios can be agonizing and vexing for patients, family members, physicians, insurance company personnel, the public, and juries to sort out.   I have no easy formula to offer readers.

Just because a doctor recommends a treatment, doesn’t mean it is established care.  And, just because an insurance company denies a treatment, doesn’t mean the company is evil.

Michael Kirsch is a gastroenterologist who blogs at MD Whistleblower.

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