Posting this for a coworker. It’s a self-funded plan. She had a mammogram that led to a biopsy and then a PET scan. She’s now diagnosed with HER2-positive breast cancer. A port has been placed, and she was supposed to start chemo this week, but UMR has denied it, saying it’s not necessary. Why would this happen?
I haven’t spoken much with her about the details because she’s trying to keep this private. The company is very focused on money and has even mentioned firing people who cost too much. There’s a stop loss in place, so they’ll probably figure it out when that’s reached. Until then, she can’t go to HR about it. I’ve suggested she reach out to UMR directly if she hasn’t already. Any advice?
The doctor needs to send detailed records proving medical necessity. This often happens when the insurance company doesn’t have all the information they need. Check with the doctor’s office—they might already be working on it.
The denial letter will explain the specific reason. They can’t just say it’s unnecessary—they have to provide medical reasoning. She and her doctor should work together on an appeal, providing evidence to counter the denial.
They might think the cancer could be treated with surgery and radiation alone, but HER2-positive is an aggressive form of cancer. Her doctor will likely need to provide detailed justification for chemo.
If she needs help with the appeal, I’d be happy to assist. Self-funded plans are governed by ERISA, which requires employers to act in the beneficiary’s best interest. Given the urgency of her treatment, an expedited appeal may be possible.
@Riley
Patients have rights to appeal outside the provider network. Insurers must use a board-certified doctor in the relevant specialty to review the case. If the appeal process feels overwhelming, encourage her to seek outside help.
Her doctor’s office needs to handle the appeal as soon as possible. There are multiple levels of appeal, with the final step being a peer-to-peer review between her doctor and an insurance-appointed doctor. Encourage her to ask for a copy of the denial letter, as it will have instructions on how to appeal.
If she’s at an in-network hospital, they should have a team dedicated to handling appeals. She might just need to confirm they’ve received the denial and are working on it.