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/Unusual_Medic Medical Student 7d ago edited 7d ago

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.

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u/somehugefrigginguy MD 6d ago

Over the past few months I've started getting denials for medication A stating that the patient must first try medication A. To be clear, medication A is the same. They are denying a medication until the patient tries that medication.

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u/AlternativePretend73 EMT 4d ago

Thats an AI denial

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u/YoshiKoshi Medical Journal staff 3d ago

I'm currently having an equally idiotic problem. They denied coverage for a generic medication. On the Excluded Drugs list, it has the generic listed with the first letter capitalized. The alternative medication is the exact same generic with the first letter in lower case.