Why Might You Receive a CRISPR Insurance Denial?
Of course, the specifics associated with your CRISPR insurance denial will dictate how you respond. CRISPR is a relatively new technique—and is expensive—so it likely has a higher risk of being denied by your insurer. Insurance companies are focused on their financial bottom lines and will deny more expensive treatments using words like “experimental,” “not medically necessary,” and “investigational.”
While some reasons for a CRISPR insurance denial may be fairly easy to correct and obtain a reversal, the above reasons can be more difficult, usually requiring that you go through the appeal process. When you are not in good health and not feeling well, facing the appeal process can seem entirely overwhelming. You can benefit significantly from having a strong legal advocate like attorney Scott Glovsky in your corner.
Clustered Regularly Interspaced Short Palindromic Repeats (CRISPR) is essentially technology that can “edit” genomes. The CRISPR technique targets precise genetic codes, and then “edits” the affected DNA. CRISPRs were first discovered in archaea (a group of micro-organisms similar but distinct from bacteria), then later in bacteria by a scientist in Spain. CRISPR “spacer” sequences are transcribed into short RNA sequences that can then guide the system to find the target DNA.
What Should You Do Following a CRISPR Insurance Denial?
Following a CRISPR insurance denial, you do have options. Insurance companies count on the fact that very few people who receive an insurance denial will engage in the appeal process. You have the right to appeal the denial of benefits for covered services that your physician believes are medically necessary for you. You will first file an internal appeal that will benefit from a letter from your physician clearly detailing why CRISPR is necessary. You usually have 180 days following a denial from your insurer to file an internal appeal, asking your insurance company to reconsider its original decision.
If your life, health, or ability to function could be in jeopardy because of the CRISPR insurance denial, you can file an expedited appeal with your insurance company. If your insurer still refuses to pay for CRISPR, you can move to the next step, which is an external appeal. An external appeal is filed with a neutral third party who will review the denial and determine whether your insurance company should pay for the CRISPR treatment. Your internal appeal denial notice should provide information on how you will request an external review. New information can be submitted during the external review to support your position that CRISPR should be paid for by the insurer. But it is important to note that we recommend speaking with an experienced health insurance denial attorney before you request an external appeal. The reason is that in your specific situation, it might be better to take legal action.
What Specific Insurance Companies Are Known to Deny Treatments?
Any insurance company can potentially deny a treatment your doctor has prescribed, although some may be more likely to do so than others. Some of the California insurers who may issue a CRISPR insurance denial include:
What Diseases Can Benefit from CRISPR?
There is a very long list of diseases that could potentially benefit from CRISPR, including (but not limited to) the following:
- Acute lymphoblastic leukemia
- Acute myeloid leukemia
- Age-related macular degeneration
- Alzheimer’s
- Beta thalassemia blood disorder
- Bordetella pertussis
- Hepatitis B
- Cystic fibrosis
- Covid
- Type 1 diabetes
- Epithelial ovarian cancer
- HIV
- Huntington’s disease
- Muscular dystrophy
- Retinitis pigmentosa
- Sickle cell disease
How Expensive is CRISPR and When Did It Gain FDA Approval?
The CRISPR one-time treatment for sickle cell disease can potentially relieve a lifetime of medical hardship, however, Vertex Pharmaceuticals and CRISPR Therapeutics, who have partnered on this treatment called Casgevy, say the price for CRISPR is $2.2 million per person. The cost alone will result in many insurance companies denying the CRISPR treatment. CRISPR received FDA approval for this treatment of severe sickle cell disease on December 8, 2023. Now that it is approved, this genetic therapy could benefit at least 20,000 people currently living with severe sickle cell disease in the United States.
Casgevy received FDA approval to treat the inherited blood disorder transfusion-dependent beta thalassemia (TDT) on January 16, 2024. Today, healthcare costs to treat TDT are more than $5 million over a patient’s lifetime. So while expensive, Casgevy’s one-time treatment cost of $2.2 million is less than the cost of alternative treatments.
On April 10, 2024, CMS proposed giving hospitals who administer expensive gene therapies like Casgevy an additional 75% of treatment costs on top of existing Medicare treatment payments. This amount adds 10% to the current 65% additional hospital payments for utilizing new technologies. Of course CMS must categorize Casevy as a new technology and the additional 10% applies only during the “newness period.”
How Can the Law Offices of Scott Glovsky Help with a CRISPR Insurance Denial?
If you or a loved one has received a CRISPR insurance denial, you must speak to a knowledgeable legal advocate from the Law Offices of Scott Glovsky. Attorney Scott Glovsky initially worked on the other side of the aisle, on behalf of big insurance companies, so he is well-versed in how they work and what tactics they are likely to use. Scott now fights aggressively and tirelessly for his clients who are suffering as a result of an unfair insurance denial. Scott and his legal team have a solid reputation in the industry and are well-respected by all those involved in the insurance denial process. Our firm offers highly personal and caring client attention, deliberately taking fewer cases so we can devote the time and care necessary to each client. If having an attorney who exhibits passion, commitment, and hard work—and who has a highly successful track record—is important to you, contact the Law Offices of Scott Glovsky.