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The Lifecycle of an Appeal (Part 1)

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    Name
    Mike Gartner, PhD
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Introduction

In this multi-part post, I'll walkthrough an appeal of a coverage denial that I just received from my old health insurer, and post about progress as it occurs. My hope is that a resource documenting an appeal playing out in real time, with all the gory details, will be a useful guide for others appealing insurance denials1. It's possible we'll even win the appeal in the process, but no promises on that front; there are a lot of factors at play.

Background

I have a chronic medical condition (Crohn's Disease), and to treat it I take an expensive, self-administered injectable drug (Adalimumab, or brand name Humira) that has many potential side effects. The drug is known to have highly variable efficacy for treating my condition, in part due to immune response to the drug that can occur in certain patients. Such immune response can be detected in various ways through blood tests. As a result, it's common (and useful) practice for physicians who prescribe this medication for their patients to routinely keep tabs on the effectiveness of the drug, and on the status of the drug in the patient's blood. Here status means both checking for the amount of the drug in the patient's blood (to ensure a patient is receiving and correctly administering the expected dosage), and checking for antibodies to the drug in the patient's blood (which helps inform expected efficacy, and decisions to change dosage, in each particular case).

In addition to such testing having plainly understood utility on an intuitive level, it's utility also happens to be backed up by a significant body of science. See e.g. [1] (Gonczi et al., 2017) , [2] (Papamichael et al., 2019) , [3] (Assa et al., 2019), and [4] (Mitrev et al., 2017) for just a few examples.

The Coverage Scenario

Late last fall my doctor advised me to get blood tests to check the level of Adalimumab in my blood. Independent third party labs often do the processing for this test, and partner with more common labs to do the phlebotomy and mail them the necessary blood samples. I made an appointment to get blood drawn for the test (and to have some additional standard blood tests performed, while I was there) at a lab associated with a local nonprofit hospital. I chose an outpatient lab associated with a hospital over much more convenient labs because it was one of a small group of locations near me that partner with a specialty lab capable of testing my blood for the drug levels ordered by my physician.

A month later, I received a $1500 bill from the nonprofit hospital. To my surprise the nonprofit hospital had charged an outrageous price2 for the two standard blood tests I had received countless times before; this bill did not even include the yet-to-be-processed level test which was the main purpose of my appointment. This price gouging from a non profit hospital was pretty upsetting, but there was not much to be done3, since I had not done my due diligence in this case and looked up the hospital's rates for these standard tests in advance. I ultimately ate this charge and moved on with my life.

Two months after that, I received another bill, this time for $2500, for the (less standard) drug level tests. This one really caught me off guard. This test was one that my doctor had helped me arrange with the third party lab; I had spent a significant amount of time on the phone with representatives from the lab, and speaking with my doctor's office, before scheduling it. I was informed by all involved if I got my blood drawn at a partner organzation of a particular third party lab, I could ensure a low out of pocket cost after insurance ($75, to be precise). So this is precisely what I did. Why then had I just received a $2500 bill in the mail?

I spoke with the third party lab, and they informed me that while they do have a program that ensures low out of pocket costs for patients, this program only comes into effect on request4, and only after an attempt has been made to bill insurance. For some reason, the forwarding order for the tests from the hospital's lab had not included my insurance information5, so my insurance had never been billed. I gave the representative from the third party lab my insurance info, and they told me that they'd retroactively submit a claim to my (now out of date) insurance plan, and we'd proceed based on their coverage decision.

I sighed the joyous relief of putting this particular blood draw in my past.

References

Assa, A., Matar, M., Turner, D., Broide, E., Weiss, B., Ledder, O., Guz-Mark, A., Rinawi, F., Cohen, S., Topf-Olivestone, C., Shaoul, R., Yerushalmi, B., & Shamir, R. (2019). Proactive Monitoring of Adalimumab Trough Concentration Associated With Increased Clinical Remission in Children With Crohn’s Disease Compared With Reactive Monitoring. Gastroenterology, 157(4), 985-996.e2. https://doi.org/https://doi.org/10.1053/j.gastro.2019.06.003
Gonczi, L., Kurti, Z., Rutka, M., Vegh, Z., Farkas, K., Lovasz, B. D., Golovics, P. A., Gecse, K. B., Szalay, B., Molnar, T., & Lakatos, P. L. (2017). Drug persistence and need for dose intensification to adalimumab therapy; the importance of therapeutic drug monitoring in inflammatory bowel diseases. BMC Gastroenterol, 17(1), 97.
Mitrev, N., Vande Casteele, N., Seow, C. H., Andrews, J. M., Connor, S. J., Moore, G. T., Barclay, M., Begun, J., Bryant, R., Chan, W., Corte, C., Ghaly, S., Lemberg, D. A., Kariyawasam, V., Lewindon, P., Martin, J., Mountifield, R., Radford-Smith, G., Slobodian, P., … Leong, R. W. (2017). Review article: consensus statements on therapeutic drug monitoring of anti-tumour necrosis factor therapy in inflammatory bowel diseases. Aliment Pharmacol Ther, 46(11–12), 1037–1053.
Papamichael, K., Juncadella, A., Wong, D., Rakowsky, S., Sattler, L. A., Campbell, J. P., Vaughn, B. P., & Cheifetz, A. S. (2019). Proactive Therapeutic Drug Monitoring of Adalimumab Is Associated With Better Long-term Outcomes Compared With Standard of Care in Patients With Inflammatory Bowel Disease. J Crohns Colitis, 13(8), 976–981.

Footnotes

  1. While there are a plethora of appeal letter templates one can find around online, it's less common to actually see these filled out in real scenarios, and witness successful or failed appeal attempts, so the hope is these posts supplement those resources. ↩

  2. Of the two standard blood tests I receieved, one was ~10-20x the average price for the test across the U.S. The CPT code was 80053 (a comprehensive metabolic panel), and the total negotiated charges billed to my insurance for the test was $1083. For comparison, the medicare reimbursement limit for that test in 2018 was ~$15 (see e.g. this document from the college of american pathologists), according to numerous aggregation sites the average out of pocket cost for the insured for this service across the U.S. is ~$50 (see e.g. this aggregator), and the national, easily accessible lab Quest Diagnostics charges ~$50 for the test for those without insurance (see here). Ouch. ↩

  3. I tried to get my state attorney general's office involved via a complaint about this clear price gouging by a tax-exempt organization, but that ended up going nowhere, and is a story for another post. ↩

  4. This was never mentioned in my prior conversations with the lab. ↩

  5. This made the $1500 bill for the hospital's standard services sting a bit more. ↩