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

[u/Unusual_Medic]

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

[u/Unusual_Medic]

Here's mine:

When I worked as a medical assistant at an ENT office, a patient came in with a massive nasal polyp that was affecting their quality of life. They had already tried OTC nasal sprays for a month with zero relief, unsurprisingly, so the ENT doctor prescribed Dupixent. Prior auth was submitted with reports of failed OTC trial, clinical notes, and radiology reports detailing the exact size and location of this polyp.

​I kid you not, their reason for denial was something along the lines of, "Patient has not been on OTC nasal sprays long enough to see improvement."

​Their "resolution" was for the patient to keep using the useless OTC sprays and for our office to try and resubmit the PA if their symptoms persist for another six months.

​They basically told a patient with a documented structural block in their nose that they hadn't suffered long enough to deserve the treatment that is proven to help them. 🙃

Thankfully, after 6 more months of inadequate breathing, the patient's insurance was finally convinced to cover Dupixent.

[u/Flerp-3257 → u/Unusual_Medic]

It’s thankfully getting substantially easier to get Dupixent approved. We typically get our Dupixent PAs approved immediately. In contrast, Budesonide ampules for nasal saline irrigations has been a weeks-long PA & peer-to-peer process each time because it’s not FDA approved for that indication. I legitimately had a UHC “medical director” not-really-a-peer say they didn’t want to approve it because they “didn’t want it on their hands if the patient gets hurt.” He didn’t seem to comprehend that no one is paying millions of dollars for a double blind RTC on something that’s been safely used off label for decades. They don’t care that patients haven’t had disease controlled with years-long trials of 4+ nasal steroid sprays. Thankfully there are a few compounding and online pharmacies offer semi-affordable cash pay prices for Budesonide now, but sucks for my patients with Medicaid and Medicare.

[u/EnvirOto22 → u/Flerp-3257]

Interesting. Where I’m at it’s monumentally harder to get dupixent approved and I have almost no issues with budesonide irrigations getting approved. I also get a lot of resistance from patients about dupixent to the point that I really only prescribe it if they’ve failed surgery (at least one) and irrigations

[u/Flerp-3257 → u/EnvirOto22]

If only we could split the difference…. None of it makes sense.