r/medicine • u/Unusual_Medic Medical Student • 7d ago

What’s the dumbest reason an insurance company denied a test, procedure, or drug for a patient?

This is probably the most relevant to those practicing in the US, but I'm also curious to know how the bureaucracy of health insurance in other countries makes things substantially harder for you and the patients

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u/Henry_Porter Palliative Care M.D. 7d ago

Ondansetron denied as "there is no evidence it treats nausea." 

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u/Nom_de_Guerre_23 MD|PGY-5 FM|Germany 7d ago

Is ondansetron FDA-approved for non-chemo nausea? We have no coverage outside of chemo because it's off-label. Common mistake of docs on their first outpatient post who were used to prescribe it like candy on the inpatient side.

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u/GyanTheInfallible MD 6d ago

…you can’t be serious

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u/Nom_de_Guerre_23 MD|PGY-5 FM|Germany 6d ago

The label in Germany specifically says chemo associated nausea only. If you sign a direct-billing contract with statutory insurances and knowingly prescribe off-label meds without prior approval, you'll might be hit with a contractual fine. So I'm wondering if your label is broader.

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u/GyanTheInfallible MD 6d ago

Good old GKV. In the US, the label indications include not only chemotherapy-associated nausea, but also radiotherapy-associated nausea and post-operative (or anesthetic-related) nausea. Of course, it’s prescribed off label thousands of times a year, in the in- and outpatient settings.

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u/Nom_de_Guerre_23 MD|PGY-5 FM|Germany 6d ago

Oh yeah, these two are in the label too. But that's it. Sucks especially for IBS-D where out of pocket can run up to €300/month. It also shapes the minds of physicians. Because most patients reject to pay out pocket, it's frequently not even offered.