According to breastcancer.org, breast cancer accounts for about 30 percent of all new cancer diagnoses among women each year and 12.5 percent of all new annual cancer cases. Across the United States, one in eight women will develop invasive breast cancer over the course of their lifetime. A man’s lifetime risk of breast cancer is about one in 833. As of January 2022, there were more than 3.8 million women in America with a history of breast cancer—both those currently being treated for the disease and those who have completed treatment. Although the incidence of breast cancer has risen about 0.5 percent each year since the mid-2000s, mortality rates have been decreasing according to the American Cancer Society.
Receiving a diagnosis of breast cancer is, understandably, one of the worst things you may have faced in your life. Now imagine how it would feel to have a treatment that could potentially save your life denied by your health insurance company. Perhaps this has already happened to you or to a loved one. It can be frustrating and frightening when your doctor prescribes a course of treatment meant to help you have a future—then your insurer denies that treatment.
This is a time in your life when you desperately need an advocate—a person who believes in your right to receive life-saving medical treatments and who will hold big insurance companies accountable to those they insure. That advocate is attorney Scott Glovsky. Scott helps Californians receive the treatments they need and deserve—and have paid for through years of health insurance premiums. Scott and his legal team work tirelessly for clients who feel lost and hopeless after an insurance denial of a treatment they need.
Why Was Your Breast Cancer Treatment Denied by Insurance?
If your health insurance company has refused to pay for a breast cancer treatment your doctor believes you need, it can be disheartening—to say the least. Claim denials are standard in the industry as insurers strive to have a very healthy financial bottom line. In fact, according to cancersupportcommunity.org, about 40.4 million health insurance claims were denied in 2019, yet less than .02 percent of those denied claims were appealed. Since up to 60 percent of claims that are appealed will eventually obtain favorable results, challenging an insurer’s decision is definitely the right thing to do.
There are many reasons for a breast cancer treatment to be denied by insurance. In some instances, a simple paperwork error could be the culprit, such as a billing code error, or paperwork that is not properly or completely filled out. Other times, a treatment could be denied, ostensibly because the treatment is not “medically necessary,” is “experimental,” or is “investigational.” If your doctor prescribed the treatment for your breast cancer then he or she believes it is the best course of action for you, giving you the best chance of beating your breast cancer.
It is interesting to note that insurers are highly unlikely to ever deny a drug or treatment citing it as medically unnecessary, investigational, or experimental, unless the treatment or drug is also expensive. Your insurer may require you to try different (i.e., less expensive) options first, but might eventually pay for the treatment. For prescription drugs, this is known as “step therapy,” and while it can be exhausting for the patient, the insurer will eventually pay for the prescribed treatment.
An outright denial means the insurer is not even willing to go through the process of trying less expensive therapies and drugs first. At the Law Offices of Scott Glovsky, Scott and his legal team see cases like this every day. We never hesitate to go up against a huge billion-dollar insurance company on behalf of our clients. Early in his career, Scott worked for insurance companies so he knows the tricks they may use to deny claims. Having a strong advocate in your corner is essential following a breast cancer treatment insurance denial and Scott Glovsky is that advocate.
What Should You Do if Your Health Claim is Denied by Your Insurer?
Following a breast cancer treatment insurance denial, you have options, and Scott Glovsky can help you explore these options. Your first course of action could be to have your doctor write a letter to your insurer detailing why the breast cancer treatment is necessary for your health. If your health insurance company still refuses to pay for the treatment, your next course of action could be to file an internal appeal with your insurer, asking it to reconsider its decision. Your doctor’s letter would be a part of this appeal, along with your original denial letter, and information as to whether this same treatment has been approved for other patients.
If your case is considered urgent, you can file an expedited appeal and your insurance company must provide you with a determination within 72 hours. If the treatment requested has not already been received, your insurer has 30 days to respond with a decision, and if you have already received the treatment and are seeking reimbursement, your insurer must respond with a decision within 60 days. If your internal appeal results in an affirmation of the denial, you can file an external appeal with an independent review organization that will review your claim and make a final decision.
Are There Specific Insurance Companies That Are More Likely to Deny Treatments?
All health insurance companies deny treatments—most particularly, those treatments that are expensive. While some health insurers may be more likely to deny treatments than others, Californians may experience denials from Anthem Blue Cross, Blue Shield, Health Net, Kaiser, UnitedHealthcare, Aetna, and others. Regardless of which insurer has issued your breast cancer treatment insurance denial, attorney Scott Glovsky is ready to fight for your right to get the treatment you need and deserve.
What Drugs Are Typically Prescribed for Breast Cancer?
Targeted drug therapy uses medications to target the proteins in breast cancer cells that allow those cells to grow, spread, and live longer. Some targeted breast cancer therapy drugs like monoclonal antibodies work in more than one way to control cancer cells, and, because they boost the immune system, may also fall under the immunotherapy heading. Targeted drugs can work even when chemotherapy drugs do not. There are different types of targeted therapies for breast cancer, including:
- About 15-20 percent of breast cancers involve cancer cells that make too much of HER2 positive—a cancer cell growth-promoting protein. These cancer cells tend to grow and spread in a much more aggressive manner than HER2-negative breast cancers. Monoclonal antibodies are man-made immune system proteins that attach to HER-2 proteins in cancer cells to inhibit the growth of those cells. These drugs include trastuzumab (Herceptin), pertuzumab (Perjeta), and margetuximab (Margenza).
- Antibody-drug conjugates are linked to a chemotherapy drug; the anti-HER2 antibody acts like a “homing signal,” by attaching to the HER2 protein on cancer cells, bringing the chemotherapy treatment directly to them. Drugs in this class include ado-trastuzumab emtansine (Kadcyla), and fam-trastuzumab deruxtecan (Enhertu).
- Kinases are proteins in cells that normally relay signals, telling a cell to grow—even a cancer cell. Drugs that block these kinases are called kinase inhibitors like lapatinib (Tykerb), neratinib (Nerlynx), and tucatinib (Tukysa).
Targeted therapies for hormone receptor-positive breast cancers include CDK4/6 inhibitors like Ibrance, Kisqali, and Verzenio. These drugs block proteins in the cells called cyclin-dependent kinases. Blocking these proteins can help stop the cells from dividing, thus slowing cancer growth. mTOR inhibitors block mTOR, which is a protein in cells that helps them grow and divide. Drugs like everolimus (Afinitor) block mTOR, stopping tumors from developing new blood vessels, and thus limiting their growth.
PI3K inhibitors like alpelisib (Piqray) can be used to treat advanced hormone receptor-positive HER2-negative breast cancer with a gene mutation that has grown during or after aromatase inhibitor treatment. It is estimated that 30-40 percent of breast cancers have this mutated PIK3CA gene. Drugs known as PARP inhibitors, like olaparib (Lynparza) and talazoparib (Talzenna) stop gene mutations from occurring by blocking PARP proteins. These are just a few of the commonly prescribed breast cancer drugs; unfortunately, many of these drugs are also expensive, therefore, are routinely denied by insurers. As an example, Ibrance costs $13,500-$15,886 for 21 tablets, Kisqali costs $6,064-$15,162 per month, and Lynparza costs $8,374 for a 60-tablet supply.
Are There New Treatments for Breast Cancer?
The FDA approved a new targeted therapy for advanced, hard-to-treat breast cancers at the end of January 2023. The new drug, elacestrant, addresses an unmet need and is the first and only treatment approved specifically to fight mutations in an estrogen receptor called ESR1. These mutations make breast cancer resistant to standard treatments and are present in about 40 percent of all metastatic or advanced breast cancers that are HER2 negative and estrogen receptor positive. While elacestrant was initially developed to treat post-menopausal hot flashes, it is believed this drug has the potential to become the endocrine therapy of choice in late-stage breast cancer.
On November 16, 2023 the FDA approved Truqap (capivasertib) in combination with the older medication fulvestrant, offering yet another treatment option for those with the most common type of breast cancer. Truqap will treat adults with hormone receptor (HR)-positive, human epidermal growth factor receptor 2 (HER2)-negative locally advanced or metastatic breast cancer with 1 or more PIK3CA/AKT1/PTEN-alterations. At the same time, the FDA approved the diagnostic FoundationOne®CDx assay to help identify breast cancer patients to be treated with Truqap.
How Can Attorney Scott Glovsky Help with Breast Cancer Treatment Denied by Insurance?
A breast cancer treatment insurance denial can be devastating. At a time when you are fighting to save your life, having your insurance company turn its back on you is like adding insult to injury. Like most Americans, you purchased insurance for your peace of mind, hoping you will never need it, yet you pay your insurance premiums every month to protect yourself against the unthinkable. In return, you expect your insurance company to be there when you need it. Unfortunately, insurance companies are much more interested in their financial bottom lines than in helping those diagnosed with a frightening disease. Attorney Scott Glovsky fights for his clients to ensure they are not taken advantage of by their insurers, taking on any act of bad faith, and forcing insurers to fulfill their promise to you. Contact the Law Offices of Scott Glovsky today for the help you need.