When you need a specific treatment for an illness, injury, or disorder, it can be extremely frustrating to find that your insurance company has denied what your doctor prescribed. While insurers often cloak their reasons for a denial behind words like “experimental,” “not medically necessary,” or “investigational,” these denials often come down to cost. An insurance company is unlikely to deny your treatment if it is inexpensive, regardless of how “experimental” it might be.
Unfortunately, Acthar® Gel may fall into this category. Questcor acquired the rights to Acthar® Gel in 2001, subsequently raising the price of the drug from $40 a vial to more than $31,000 per vial. Mallinckrodt then acquired Questcor—primarily as a result of the high price of Acthar® Gel —and raised the price even more, by 26 percent. This makes the cost of Acthar® Gel almost $40,000 per vial at present. Yet many people can benefit significantly from Acthar® Gel, and when an insurer issues an insurance denial for Acthar® Gel, the results can be devastating.
What is Acthar® Gel and What Is It Used For?
Perhaps your doctor has prescribed Acthar® Gel for a chronic inflammatory or autoimmune condition. Acthar® Gel is administered as an injection, either under the skin or into the muscle, and is a mix of proteins and natural hormones that mimic those that already exist in your body. Acthar® Gel is not a steroid, rather it interacts with melanocortin receptors, working with your immune system to help reduce inflammation in the body.
According to an article in Time Magazine, while inflammation is meant to protect our body against trauma, poisons, and pathogens, it is not always helpful—or harmless. Autoimmune diseases like rheumatoid arthritis, lupus, and IBD develop because of inflammation that disrupts the body’s essential functions, tearing down tissues. Today we know that inflammation plays a major role in many chronic conditions, including diabetes, obesity, cancer, and heart disease. In fact, “low-level, invisible inflammation, simmering quietly in the blood of ostensibly healthy people, may be a common thread running through nearly all diseases.”
Why Claims Associated with Acthar® Gel May Be Denied
As noted, if your claim for Acthar® Gel has been denied, it could be largely due to the price of the drug. Acthar® Gel was approved by the FDA in 1952 and sold for decades at less than $40 per vial. A 2020 drug pricing investigation by the U.S. House of Representatives, specifically looked at Acthar® Gel because of the more than 100,000 percent increase in price since 2001, and because Mallinckrodt generated nearly 6 billion in net sales of Acthar® Gel from 2014 through 2019. While Congress should definitely address overpriced medications like Acthar® Gel, patients who can benefit from the drug should not receive insurance denials.
What Can You Do About an Acthar® Gel Insurance Denial?
If your health insurer refuses to pay a claim, you do have options. You can file an internal appeal, asking that the insurance company reconsider its decision. Insurance companies must tell you why your claim was denied, and the process for disputing that decision. In an internal appeal, you will ask your insurance company to conduct a full and fair review of your Acthar® Gel insurance denial. It can be helpful to get your doctor to write a letter to your insurance company that details why you need Acthar® Gel for your health. If your internal review is unsuccessful, you can ask for an external review. In an external review, an independent third party will have the final say over whether a claim should be paid. We recommend that you speak with an experienced health insurance attorney before you file an external appeal since this lawyer may tell you to follow a different path.
Specific Insurance Companies That Are Known to Deny Acthar® Gel Prescriptions
While any insurance company could potentially issue a denial for Acthar® Gel, some insurers may be more likely than others to do so. The following California insurance companies may deny your doctor’s order for Acthar® Gel:
How Can Inflammatory Diseases and an Acthar® Gel Insurance Denial Can Affect My Life?
Acute inflammation refers to the body’s response to sudden body damage, such as cutting your hand. In order for the cut to heal, inflammatory cells are sent to the injury site to begin the healing process. Chronic inflammation occurs when the body continues sending inflammatory cells, even when there is no outside “danger.” These inflammatory cells can attack joint tissues, causing severe damage to joints, along with pain and even deformities.
Tuberculosis, rheumatoid arthritis, HIV infection, psoriasis, Alzheimer’s disease, asthma, cancer, Type 2 diabetes, heart disease, lupus, ankylosing spondylitis, sarcoidosis, inflammatory eye conditions, and multiple sclerosis are just some of the chronic inflammation conditions that can benefit from Acthar® Gel. Your quality of life can be significantly affected by these conditions, and it can even become difficult for you to accomplish normal everyday tasks, let alone keep a regular job.
How the Law Offices of Scott Glovsky Can Help with an Acthar® Gel Insurance Denial
If you or a loved one is facing an Acthar® Gel insurance denial, you need a strong advocate in your corner. Attorney Scott Glovsky and his highly skilled legal team can be that advocate. Scott Glovsky tells potential clients, “If results matter, then hire us.” Scott founded the Law Offices of Scott Glovsky in 1999 to hold large insurance companies accountable for placing profits ahead of people.
Scott’s goal is to make a real, lasting difference in the lives of his clients. Scott and his legal team are highly experienced, well-respected, and have a stellar reputation in the industry. When you choose the Law Offices of Scott Glovsky, you will find that you and your health are a priority. Scott gets to know his clients, their families, and the story behind their suffering. Contact the Law Offices of Scott Glovsky today.