Sunday, February 17, 2019

Insurance Company Denies Coverage for Drug


A patient came to see me recently with a suspicion that his colitis was recurring.   In general terms, colitis describes a condition when the large intestine is inflamed or irritated.  Typical symptoms are diarrhea, abdominal cramping and rectal bleeding.  This patient was concerned as his last 3 bowel movements were diarrhea.  He had been on a medicine called mesalamine, a safe and effective treatment for colitis, but he ran out of it 2 weeks ago.  While he was taking the medicine, he felt perfectly well.  So, his bowel change developed 2 weeks after he ran out of his medicine. 

For readers who like to play doctor, choose among the following options:
  • Schedule an urgent colonoscopy to verify that nothing has changed since his colonoscopy 6 months ago.
  • Observe the patient without any treatment to give him time to heal himself.
  • Recommend probiotics to restore his digestive health.
  • Refill the mesalamine at his usual dosage.
  • Request a 2nd opinion because the case is mind boggling complex.
  • Prescribe an antibiotic because most cases of diarrhea are caused by an infection.
I thought that the most reasonable option was to reunite the patient with mesalamine, which had been extremely effective.  Moreover, since the symptoms developed after a 2-week medication hiatus, this suggested that his colon was pleading for a medication refill.  The patient, who is not a doctor, also thought this was the optimal choice, since he attempted to refill the mesalamine on his own prior to seeing me.  However, he had new medical insurance and their response to the routine refill request was DENIED!

My Staff and I became Gerbils

Next week, I’ll share how we responded to this frequent and frustrating development.  Don't get your hopes up.   It was a gerbilesque experience. We all felt like we were running on a wheel, expending lots of energy and effort, but with no traction. 

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