The National Comprehensive Cancer Network, a nonprofit alliance of top cancer centers, disagrees with this perspective in its widely followed cancer treatment guidelines. The network’s guidelines recommend the procedure sought by Pike for “a select group of patients after multidisciplinary evaluation and discussion in the appropriate clinical context.” Angela Pike viewed the denial as a temporary setback, believing an easy appeal was forthcoming based on the MD Anderson surgeon’s reassurances. However, despite the surgeon’s insistence that the procedure could save Tracy Pike’s life, Blue Cross and Blue Shield of Illinois continued to reject the treatment. Angela was dismayed to discover that the physician denying the treatment was not a cancer specialist but an obstetrician-gynecologist. Tracy Pike passed away in January 2024, leaving behind his wife and three children. Angela continues to grapple with the question of whether Tracy’s life could have been saved if he had undergone the surgery.
An investigation by NBC News revealed that cancer patients often face additional challenges when insurance companies refuse treatments recommended by their physicians. Furthermore, Medicare began denying claims for breast cancer imaging necessary for early detection. Patients and families find the peer review processes imposed by insurers, where a company-appointed doctor makes decisions on treatments, to be distressing. Many patients face financial burdens due to denied care, with a significant number accruing medical or dental debt.
Cancer patient Kay Hsu, who has fought her insurers for years, describes the process as debilitating and demoralizing, highlighting the immense power insurers hold over individuals’ lives. The frustration with health insurance companies came to the forefront following public outcry over United Healthcare CEO Brian Thompson’s murder in New York City. Dr. Bruce Scott, president of the American Medical Association, emphasizes the escalating challenges patients face in accessing timely cancer care due to bureaucratic hurdles in the healthcare system.
Recent academic research highlights the critical impact of health insurers’ care denials and authorization delays on cancer patients, with potential consequences as dire as loss of life. A 2022 survey by the American Society of Clinical Oncology revealed that significant delays in prior authorizations led to serious adverse events for patients, including treatment and care denials, disease progression, and even loss of life. Another study published in JAMA Network found that a substantial portion of cancer patients did not receive prescribed care due to these authorization issues, affecting both nonspecialty and specialty drugs used in cancer treatment. The burden of obtaining prior approvals has significantly increased over the years, with a rise in the percentage of drugs requiring authorization. Despite efforts to address these challenges, there has been little progress in improving the situation, as health insurers continue to prioritize profit over patient care. The denial of essential cancer treatment, as seen in the case of Tracy Pike, underscores the ongoing struggle faced by patients and healthcare providers in navigating the complex landscape of prior authorization practices.
The family’s insurance coverage was terminated when he fell ill and was unable to work. To make ends meet, they rely on his Social Security benefits. Angela Pike expressed frustration, stating, “This is the domino effect of being denied a life-saving treatment by an insurance company.”
Reforms aimed at improving patient care have been proposed, with health insurance companies claiming that requiring doctors to justify recommended procedures can save costs. However, physicians argue that several industry practices hinder patient care. These include a lack of transparency regarding approval rules, leading to time wasted on denied claims. Furthermore, doctors are often required to justify treatments to non-specialist insurance company physicians, causing delays in approvals.
Physicians also face challenges in obtaining timely approvals for treatments or tests, leading to frustration and delays in patient care. They advocate for a more streamlined process for procedures that are routinely approved, aiming to reduce unnecessary hurdles for patients.
Dr. Debra Patt, an oncologist and advocate for cancer patients, emphasized the need for responsible use of prior authorization, calling for improvements to the current system. Texas has taken steps to address delays in prior authorizations, passing legislation to exempt physicians and certain patient groups from the approval process in specific circumstances.
In addition to private insurers, Medicare has also faced criticism for denying reimbursement for cancer screenings, such as ultrasound screenings for women at risk of breast cancer. Efforts to streamline the approval process and reduce denials for necessary care continue to be a priority for healthcare advocates.
In 2023, patient records reveal that ultrasound screenings are crucial for detecting cancers that may be overlooked by mammograms, especially for women with dense breast tissue, a condition affecting nearly half of women over 40, as reported by the National Institutes of Health. However, this year, Medicare has started denying claims for breast cancer imaging necessary for identifying cancers in many women.
Dr. Madhavi Raghu, a radiation oncologist in Connecticut, shared redacted patient records with NBC News, illustrating Medicare’s refusal to reimburse ultrasound breast screenings in 2024, despite covering them in 2023. Raghu emphasized that this denial trend is concerning since it coincides with the FDA’s directive for mammography providers to inform patients with dense breast tissue about the need for additional cancer screenings, such as MRIs and ultrasounds, which Medicare is now refusing to cover.
Raghu expressed her dismay, stating, “It’s unfair to alert a patient about an elevated cancer risk and offer another test to detect it, only to require the patient to bear the cost. It pains me to witness patients diagnosed with Stage 3 breast cancer due to the lack of screening opportunities.”
NBC reached out to a spokesperson at the Centers for Medicare and Medicaid Services regarding this reimbursement shift, presenting documents that outlined the 2023 approvals and 2024 rejections. The spokesperson clarified that Medicare’s coverage policy remains unchanged, and while ultrasounds or MRIs are covered as diagnostic tests, they are not covered as screening tests by law.
Raghu pointed out the issue of a single reimbursement code for breast ultrasounds, regardless of whether they are for screening or diagnostic purposes. Consequently, Medicare’s blanket denials this year seem to categorize all breast ultrasounds as non-covered services.
Dr. Ashley Sumrall, a neuro-oncologist from North Carolina, echoed Raghu’s concerns, noting an increase in Medicare rejections for breast ultrasound claims this year and predicting a ripple effect on private insurers aligning their policies with Medicare’s decisions.
The Department of Health and Human Services did not respond to inquiries about the reimbursement changes, leaving many patients, like Kay Hsu, facing a challenging battle with insurers. Hsu, who received a breast cancer diagnosis in 2015, has spent significant time navigating insurance disputes, with her most recent issues involving Cigna Healthcare.
PET scans can be a critical tool in detecting and monitoring cancer, but their cost and insurance coverage can pose challenges for patients. In a recent case involving Kay Hsu, Cigna denied reimbursement for PET scans ordered by her doctor to assess the spread of cancer. The insurer stated that the imaging was not medically necessary for routine follow-up or monitoring in the absence of symptoms, leading to a denial of coverage for Hsu’s scans.
Hsu, a cancer survivor facing metastatic cancer, believed that PET scans were essential for monitoring her condition. Despite her offer to undergo a less costly chest CT scan as an alternative, Cigna’s unit, EviCore, also denied this request. Hsu’s employer eventually stepped in to cover the costs out of pocket after Cigna refused reimbursement.
In a significant development, a PET scan in October revealed that Hsu’s cancer had spread to her liver. Medical professionals confirmed that this metastasis would not have been detected without the PET scan, potentially altering her treatment path. Hsu expressed gratitude for her employer’s financial support, emphasizing the importance of timely and accurate diagnostics in her ongoing medical journey.
Following the denials and subsequent coverage by NBC News, Hsu raised complaints with Cigna, EviCore, the New York state attorney general, and the Labor Department. Despite receiving minimal responses prior to media involvement, Hsu’s case garnered attention after inquiries from the news outlet. Dr. David Brailer, Cigna’s chief health officer, reached out to Hsu to address her concerns, acknowledging the gaps in coverage highlighted by her experience.
In response to the situation, a Cigna spokeswoman admitted shortcomings in Hsu’s care and expressed a commitment to improving patient support. Reflecting on the challenges she faced, Hsu criticized the power dynamics of insurance companies in life-and-death decisions, urging for greater accountability and patient-centric policies in healthcare.
Hsu’s call for transparency from health insurance companies resonates with broader discussions on patient advocacy and access to essential medical services. By sharing her story and advocating for policy changes, she highlights the human impact of coverage denials on individuals battling serious illnesses like cancer.
As the dialogue around healthcare affordability and quality continues, cases like Hsu’s serve as poignant reminders of the complexities within the current system. While insurers strive to balance cost containment and patient care, the experiences of individuals like Hsu underscore the need for a more patient-focused approach that prioritizes timely and appropriate medical interventions.
Ultimately, Hsu’s journey sheds light on the intersection of healthcare, insurance coverage, and patient outcomes, sparking conversations about the ethical responsibilities of stakeholders in ensuring access to life-saving treatments for those in need.
