Insurance plans are not required to offer transplant benefits of any type, although many do. And those that do may impose restrictions on the kind of transplants covered, or for which diseases a BMT will be approved. Sometimes families find that their health insurance plan does not cover certain types of BMTs on the basis that they are experimental or investigational (i.e., not a “standard” treatment, and/or if conducted as part of a clinical trial) or not for a certain disease or condition. In other cases, certain aspects of the transplant protocol itself may not be covered, such as new drugs used in the conditioning regime, which are considered to be experimental. And some families face a coverage paradox very early on when they find that their insurance plan offers a transplant benefit, but does not cover the HLA testing of prospective donors from among family members, and/or will not cover search for an unrelated donor. Logically of course, except for autologous BMTs, there can be no transplant without a donor. Other famiies have reported that the insurance company would not cover donor testing unless a BMT was being planned right away, even when the oncologist wanted to see if there was a family match in order to make the best treatment plans for the individual patient.
What to do in case of a denial
Denials of coverage for the BMT or for any related testing and services can be appealed, but it will be necessary to act quickly to file an appeal. . Therefore, it is important to learn exactly why the coverage of a planned BMT has been denied, and what the appeal procedure is for your insurance plan. By state law, all insurance plans sold in WA are required to have an appeal process, to inform their customers about it and to explain in detail the process for appealing of a denial. There is often a several a process with several levels of appeals, with the final possibility of having a personal hearing to have your case evaluated.
You may find it helpful to read consumer guides on handling insurance appeals before getting started. The state Office of the Insurance Commissioner has helpful information, as does a state-by-state guide called A Consumer Guide to Handling Disputes with Your Employer or Private Health Plan, prepared by the Kaiser Family Foundation.
To make the appeal, you will also need to get the help of your child’s BMT center, to provide both documentation of the medical necessity of the BMT as well as the urgency with which the procedure needs to take place to save the child’s life. Sometimes denials can be resolved by having the attending physician write a letter outlining why a specific protocol, test, or BMT procedure is needed for your child, and providing references to relevant medical literature. Other times, it is necessary to quickly begin the formal appeal process.
If appeals of insurance denials are unsuccessful, some families choose to seek help from the office of an elected public official and/or to seek media attention for their child’s case.
Tip: If the issue is that the insurance company is denying coverage for a protocol drug because it is considered experimental, and appeals have been denied too, ask the BMT center if there are special funds available from the drug’s manufacturer to cover the cost. (see BMT Drugs for more on this topic).
Specialized organizations may be able to offer some guidance on appealing denials of coverage for a BMT or for certain BMT-related services. Please understand that unless stated otherwise, these organizations do not handle individual cases, but can supply you with generalized information about your type of situation and/or make referrals for legal assistance, as necessary.
BMT InfoNet Insurance Help
Attorney Referral for cases of insurance denial
Cancer Legal Resource Center
Toll-free 1- 866- 843-2572
Fax: (804) 580-2502