According to the National Institute on Aging, more than six million Americans likely suffer from Alzheimer’s, which is currently ranked as the seventh leading cause of death in the United States. Most of those who develop Alzheimer’s are 65 or older; changes in the brain from Alzheimer’s can begin a decade or more before actual symptoms appear. During these early stages, toxic changes occur in the brain, including an abnormal buildup of proteins that form tau tangles, and amyloid plaques. Healthy neurons in the brain lose connections with other neurons; they eventually stop functioning altogether and die.
The damage from Alzheimer’s initially takes place in the entorhinal cortex and the hippocampus—the areas of the brain that are crucial to the formation of memories. Memory issues are one of the first signs of Alzheimer’s, along with vision/spatial issues, impaired reasoning, difficulty finding the right word in conversation or when writing, and impaired judgment. As Alzheimer’s progresses, those with the disease may experience wandering, trouble handling money, repeating questions, personality and behavioral changes, and an increase in time when attempting normal day-to-day tasks.
Moderate to severe Alzheimer’s can result in difficulty recognizing family and friends, hallucinations, paranoia, impulsive behavior, delusions, an inability to get dressed, bathe, or eat a meal, and difficulty communicating with others. Alzheimer’s research is widespread and ongoing, and new drugs or treatments can feel like a lifeline to the loved ones of an individual with Alzheimer’s. If you or a loved one has received an Alzheimer’s disease insurance claim denial, you need experienced, knowledgeable assistance from the Law Offices of Scott Glovsky.
Overview of Alzheimer’s Treatments
While there are new treatments currently in the testing stage, the treatments most likely to be prescribed for Alzheimer’s patients include:
Leqembi (lecanemab) was approved by the FDA in January 2023 as a treatment to slow cognitive and functional decline in early-stage Alzheimer’s. Leqembi is delivered as an intravenous infusion every two weeks and is believed to remove sticky proteins from the brain that are believed to advance Alzheimer’s disease. Unfortunately, Leqembi comes with a black box warning for potential brain swelling and bleeding. The price of Leqembi is $26,000 per year, although Medicare has agreed to cover 80 percent of the cost of the drug.
Aduhelm (aducanumab), an Alzheimer’s drug that received accelerated FDA approval in 2021, will be discontinued by Biogen in 2024. Aduhelm is being discontinued according to the manufacturer, “to reprioritize its resources in Alzheimer’s disease,” but the discontinuation is not related to the safety or efficacy of the drug. Those currently receiving Aduhelm as part of a clinical trial will have access to the drug until May 1, 2024, while those receiving the drug via prescription will have access until November 1, 2024. Aduhelm works by targeting and removing specific forms of beta-amyloid that accumulate in plaques, causing cell death and tissue loss in the brain.
PET Scans—An amyloid PET scan measures the buildup of abnormal amyloid proteins in the brain—one of the key hallmarks of Alzheimer’s. The cost of an amyloid PET scan starts at $3,000 and can be considerably more, depending on location. Private insurance as well as Medicare will usually deny payment for an amyloid PET scan.
Gene Therapy—While there is no definitive cure for Alzheimer’s, gene therapy shows potential for slowing the progression of Alzheimer’s while also improving the cognitive function of those with the disease. Gene therapy involves the manipulation of genetic and molecular factors that cause Alzheimer’s in a precise manner, potentially reducing the loss of brain cells, replacing damaged neurons, and targeting beta-amyloid plaques. Gene therapy is still in the experimental stages as it pertains to Alzheimer’s.
CRISPR (Clustered Regularly Interspaced Short Palindromic Repeats system) is a gene editing process that may lead to a reduction of beta-amyloid plaques and brain inflammation with fewer undesirable side effects.
In 2023, the first blood test for assessing beta-amyloid protein was made available to consumers in the United States. AD-Detect is said to help those with mild cognitive impairment identify their risk of developing Alzheimer’s Disease.
Overview of the Most Common Reasons Alzheimer’s Treatments Might Be Denied by Insurance
Although some treatments are denied by insurance because the paperwork was incorrectly filled out, the treatment is specifically excluded by the insurer, the treatment was out of network, or prior authorization was required and not obtained, Alzheimer’s treatments are often denied as a result of the cost. Insurers will hide their real reason behind words like “not medically necessary,” “experimental,” or “investigational.” If you’ve received an Alzheimer’s disease insurance claim denial that states your treatment or prescription medication is being denied based on one of these reasons, you have the right to appeal the decision. Attorney Scott Glovsky is ready to help guide you to file an appeal, working hard to ensure you receive the Alzheimer’s treatments prescribed by your doctor.
What Should You Do for An Alzheimer’s Disease Insurance Claim Denial?
If you’ve received an Alzheimer’s disease insurance claim denial, you can file an internal appeal, which essentially asks that your insurer reconsider the decision to deny your claim. If your internal appeal still results in a denial of your claim, you can file an external appeal. The external appeal asks a neutral third party to make a decision regarding your claim. If the external decision is in your favor, then your insurer must pay for the Alzheimer’s treatment it initially denied. Scott Glovsky can assist you to file the appeal, working hard to ensure the insurance company is required to pay for your treatment. Prior to filing an external appeal, however, we recommend speaking with an attorney because your best course of action may not be an appeal.
What Insurers Are Most Likely to Deny Alzheimer’s Treatments?
According to AP News, many insurers are balking at paying for the Alzheimer’s drug Leqembi—even though it is the first drug that has convincingly been shown to slow the cognitive decline caused by Alzheimer’s. Some of the insurers saying “no” to the drug include Blue Cross and Blue Shield in New York, Pennsylvania, Delaware, and West Virginia, as well as those same companies in other states. In the state of California, any of the following companies may issue an Alzheimer’s disease insurance claim denial.
- Anthem Blue Cross
- Blue Shield
- HealthNet
- Kaiser
- UnitedHealthcare
- Aetna
- and others
How the Law Offices of Scott Glovsky Can Help with Your Alzheimer’s Disease Insurance Claim Denial
If you have received an Alzheimer’s disease insurance claim denial, your first phone call should be to the Law Offices of Scott Glovsky. Our cases have impacted millions of insurance policyholders by forcing insurance companies to change their behavior—including the process of reviewing requests for medically necessary treatments. When you choose the Law Offices of Scott Glovsky, you will find that we listen to your story, and then carefully craft a strategy that will help ensure you get the treatments you need and deserve. Since 1999, attorney Scott Glovsky and his legal team have been helping those denied medical treatments or prescription drugs. You deserve to know all your legal options and you deserve an advocate in your corner who will fight for you and your future. Contact the Law Offices of Scott Glovsky today.