Why Might You Receive a CAR T-Cell Therapy Treatment Denial?
Any medical treatment—including CAR T-cell therapy—can be denied by insurance. Some insurance denials are easy to fix, including coding errors, failure to provide proper documentation or errors, and missing information on forms. CAR T-cell therapy denied by insurance could also be labeled as “not medically necessary,” “experimental,” or “investigational” by an insurer simply because the company does not want to pay for the treatment.
Insurance companies tend to focus on their financial bottom lines and since most people will not appeal an insurance decision, they can save money by denying the treatment out of hand. While it is understandable that at a time when you are not well, going through the appeal process can be overwhelming, you can have a strong legal advocate in attorney Scott Glovsky and his team. We help people just like you every single day, working hard to ensure you get the medical treatments you need.
What Should You Do for CAR T-Cell Therapy Denied by Insurance?
You must look at your insurance denial letter to determine why your CAR T-cell therapy was denied. If your therapy was denied because of an error, then it can likely be easily fixed. If one of the other reasons detailed above is given as the reason for denial, your recourse is to file an internal appeal. The internal appeal asks your insurer to take another look at your request for CAR T-cell therapy. You may include a letter from your doctor that details why the treatment is necessary. If your insurer still denies your CAR T-cell therapy, you have the right to ask for an external appeal. This external appeal will be reviewed by a neutral third party, and the decision is binding on your insurance company. We recommend before you do, however, that you speak with a highly experienced health insurance denial attorney. The reason is that this person may recommend you take a different path.
What Specific Insurance Companies Are Known to Deny Treatments?
A CAR T-cell therapy denied by insurance can occur with virtually any insurer but may be more likely with some insurers over others. Recently, an insurance company denied CAR T-cell therapy to a Michigan man, even though Michigan law requires coverage of cancer drugs. CAR T-cell therapy “weaponizes” a patient’s own cells to halt the disease and has extended the lives of hundreds of patients who otherwise had little chance of survival.
While in this case, the insurer was forced to pay for the treatment, companies in California and across the nation continue to dodge bills for more expensive treatments even as industry profits continue to rise. Insurers in California who may deny CAR T-cell therapy and other necessary treatments include:
What is CAR T-Cell Therapy?
CAR T-cell therapy is a form of immunotherapy that uses T cells (white blood cells) from a patient’s immune system to make the treatment. T cells are collected from the patient’s blood and then sent to a facility where they are changed into CAR T cells. The cells are then returned to the blood where they fight cancer by helping the body’s immune system find the cancerous cells. CARs are Chimeric Antigen Receptors and can be thought of as specialized goggles that allow T cells to locate hidden cancer cells and keep them from growing. CAR T-cell therapy is an infusion that can take several weeks to complete the entire process, but usually only is administered once.
What Illness Benefits from CAR T-Cell Therapy?
CAR T-cell therapy is generally used to treat certain types of lymphomas and leukemias, as well as multiple myeloma. CAR T-cell therapy is typically tried after other types of treatments have been used. Some of the brand names of CAR T-cell therapies include Kymriah, Yescarta, Tecartus, Breyanzi, Abecma, and Carvykti. On April 4, 2024, the FDA expanded Abecma’s approval to include treating adults with relapsed or refractory multiple myeloma after two or more prior lines of therapy. Other CAR T-cell therapies are being studied in clinical trials with the hope they will be able to treat other types of cancer as well. CAR T-cell therapies can be extremely effective for hard-to-treat cancers, giving hope to those who previously had none.
Results from a small study using CAR T-cell therapy with individuals who have autoimmune diseases such as Lupus was published in the New England Journal of Medicine in February 2024. Albeit very small with only 15 patients, the study found that this therapy seemed to be efficacious, safe and feasible for the three autoimmune disorders studied.
When did the FDA Approve CAR T-Cell Therapy and What is the Cost?
The first CAR T-cell therapy, Kymriah, garnered FDA approval in 2017. Since then, the FDA has approved five more CAR T-cell drugs from Bristol Myers Squibb, Johnson & Johnson, and Gilead, primarily to treat leukemia, multiple myeloma, and lymphoma. Because these therapies are relatively new, insurers may try to claim they are still experimental, although this is not the case. Overall, about 76 percent of patients who were given CAR T-cell therapy achieved remission, while also gaining an improved quality of life. Unfortunately, CAR T-cell therapy is extremely expensive, costing between $500,000 and $1 million, causing many insurers to deny the treatment despite the good results.
How the Law Offices of Scott Glovsky Can Help with CAR T-cell Therapy Denied by Insurance
If you or a loved one have experienced CAR T-cell therapy denied by insurance, a call to the Law Offices of Scott Glovsky can help you get the treatment you need to get better. You pay your insurance premiums faithfully, expecting your insurer to protect you and your family when you need it. Unfortunately, many insurance companies fall short of providing the support you need and deserve. Scott Glovsky and his experienced legal team will give you the time you need to get better while we work to get your treatment approved by your insurance company. Don’t wait—contact the Law Offices of Scott Glovsky today.