1/Please share this thread on behalf of my physician colleague, Eunice Stallman, who is facing the nightmare of her 9mo daughter, Zoey, being diagnosed with brain cancer several weeks ago. @BlueCrossIdaho has added to their anguish by obstructing access to vital treatment.
2/Zoey requires surgery but her tumor is too large to safely be removed. Biopsy shows she needs a targeted drug, Lorlatinib, to shrink her tumor first. Tumor boards at two separate nationally recognized children’s hospitals agreed. Now watch how many times it was denied by BC:
3/ 1. After 2 weeks of waiting, #PriorAuthorization denied due to vague “not meeting approval policy”
2. Eunice filed expedited 72 hr appeal. BC denied, stating request “not urgent” and sent to regular 14d appeal. After days calling to escalate, BC agreed to expedited appeal
2. Eunice filed expedited 72 hr appeal. BC denied, stating request “not urgent” and sent to regular 14d appeal. After days calling to escalate, BC agreed to expedited appeal
4/ 3. @bluecrossidaho then sent appeal to third party company for evaluation, MCMC. They recommend denial, stating this drug is “investigational, not standard of care, and is not medically necessary” and kicked it back to BC
4. BC took the recommendation and denied the appeal
4. BC took the recommendation and denied the appeal
5/ 5.Zoey’s doctor was able to schedule a “peer to peer” and arrived on the call to discover the “peer” was a PharmD with no oncology expertise. This was the same PharmD who had denied the prior authorization the last two times. The PharmD again, denied the appeal.
6/ @EStallmanMD then contacts an investigative journalist who notified BC of her involvement and requested appeal documents. Within hours of being contacted, BC approved Lorlatinib with a $5k/month copay and a letter that Zoey will have to undergo review again in 90 days.
7/ Doctors expect Zoey will need this drug for 6m-1y to shrink the tumor enough for surgery, costing the family an astronomical amount IF @bluecrossidaho even approves it past 90 days at all.
8/Zoey’s parents are fortunate to have connections and flexibility to take time away from work to fight these road blocks. Imagine being too sick to advocate for yourself, or non english speaking, or unable to afford taking hours off work to wait on the phone.
9/ Insurance companies are counting on it. They know that you will not have the time, knowledge, strength, or health to overcome their barriers.
10/ We must hold them accountable. Accountable to Zoey who deserves this medication for however long HER DOCTORS deem necessary. Accountable for every human in this country equally deserving as Zoey. #StandUpForZoey #StandUpForAll
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