Why Might You Receive a Kymriah Insurance Denial?
A Kymriah insurance denial can be devastating when you have been prescribed the medication for your acute lymphoblastic leukemia, B-cell lymphoma, or follicular lymphoma. Kymriah is generally used for those whose cancer went into remission, then returned, or for those whose condition did not improve after using other traditional leukemia treatments.
Among those with B-cell lymphoma or follicular lymphoma, they must have undergone at least two other types of treatments, with no positive results. A Kymriah insurance denial could be for a simple issue that you can easily fix. For some, there may be specific exclusions in their insurance policy for Kymriah and similar treatments, or prior authorization might not have been sought. If your insurance denial letter states the treatment is being denied because it is “experimental,” “investigational,” or “not medically necessary,” you have the right to appeal the decision.
What Should You Do Following a Kymriah Insurance Denial?
Unfortunately, the vast majority of people who receive a health insurance denial simply accept the denial. You have the right to appeal a denial of benefits for covered services that your healthcare provider believes are medically necessary. Further, according to jdrf.org, when these denials are appealed, more than half of all initial denials will be reversed and approved (Those with an employer plan have an even greater likelihood of having the denial reversed). You will first file an internal appeal which asks your insurer to review the denial fairly and completely. It is helpful to include a letter from your doctor that details exactly how the denied treatment will benefit you.
You should always read your insurance policy carefully, but you usually have up to six months after receiving a Kymriah insurance denial to file an internal appeal. If your life, health, or ability to function could be in jeopardy if your Kymriah claim is not approved, you can ask that your internal appeal be reviewed on an expedited basis. If the internal appeal results in a continued Kymriah insurance denial, you can request an external review that will be performed by an independent review organization.
Your internal appeal notice can be provided to the external review board. Each state’s insurance regulatory agency is usually—but not always—in charge of the external review process. You are allowed to submit new information that supports your request for approval for Kymriah. If the external review results in a reversal of your insurer’s decision to deny, your insurer is bound by this decision and must approve the benefits. When you are fighting for your life, dealing with the appeal process can seem entirely overwhelming. Having a knowledgeable attorney like Scott Glovsky and his highly experienced legal team fighting for you can make all the difference in the outcome.
What Specific Insurance Companies Are Known to Deny Treatments?
Although virtually any insurance company could deny a necessary medical treatment, it usually comes down to money. Insurers are interested in their financial bottom line and are much more likely to deny an expensive treatment than one that is more affordable. Some of the California health insurance companies that may issue a Kymriah insurance denial include:
How Common is Acute Lymphoblastic Leukemia?
Acute lymphocytic leukemia is a type of blood and bone marrow cancer that is fairly uncommon, accounting for less than half of one percent of all cancers in the United States. For the average person, the risk of being diagnosed with acute lymphoblastic leukemia is about one in 1,000 and is slightly higher among females and Caucasians. This disease is the most common type of cancer among children. Acute lymphocytic leukemia typically progresses rapidly, creating immature rather than mature blood cells. ALL occurs when a bone marrow cell develops mutations in its genetic material or DNA.
Our DNA tells our cells to grow at a certain rate and die at a certain time, but ALL interrupts those instructions, telling the bone marrow cell (cancer) to continue to grow and divide. This results in immature cells being produced that develop into the DNA mutations that lead to acute lymphocytic leukemia. While it is not entirely known what causes ALL, those who have had prior chemotherapy and radiation treatments for other types of cancer are at a higher risk. Individuals exposed to very high levels of radiation, and some genetic disorders (like Down Syndrome) can also increase the risk of developing ALL.
When Did the FDA Approve Kymriah and How Expensive Is It?
Kymriah first gained FDA approval in August 2017 for acute lymphoblastic leukemia. In May 2018, Kymriah was approved to treat patients with Large B-cell lymphoma, and in May 2022, the FDA approved Kymriah for adult patients with relapsed or refractory follicular lymphoma. Novartis, the manufacturer of Kymriah, charges $475,000 for one treatment course of this CAR T-cell cancer therapy. In August 2019, the Centers for Medicare and Medicaid Services announced that CAR T-cell therapies like Kymriah would be covered for all patients with Medicare, although co-pays continue to apply.
How the Law Offices of Scott Glovsky Can Help with a Kymriah Insurance Denial
If you or a loved one has received a Kymriah insurance denial from your health insurer, you may feel helpless, even hopeless. Kymriah is a drug that has been shown to give some people additional time with their loved ones and to have your insurer refuse to pay for the drug is devastating. The overarching goal of the Law Offices of Scott Glovsky is to help good people like you who have been wronged by an insurance company. We truly care about every client and will listen, support, and be available to you throughout the appeal process and litigation if needed. Not only will we always be honest and upfront with you, but we will also treat you with dignity and respect while we fight for your rights and your future. Contact the Law Offices of Scott Glovsky today.