What You Need To Know If Insurance Denies Coverage For Your Prescription Medication

Many people know that at Kantor & Kantor, LLP we help clients when their insurance company denies coverage life insurance claims, long-term disability claims, and eating disorder treatment claims. At Kantor & Kantor, LLP we also help clients when their insurance company denies claims for certain expensive medications including: curative Hepatitis C medications, ADHD medications and, Xyrem, a medication used successfully to treat a variety of disorders, including fibromyalgia and narcolepsy.

When Insurance Says Your Prescription Is “Not Medically Necessary”

Two women’s lives were inexplicably devastated after they attempted to fill their prescriptions for Xyrem, only to be told that their insurance company had denied coverage. One of the women, we’ll call her Jane to protect her anonymity, had been taking Xyrem for nearly a decade and the other woman, we’ll call her Mary, had been taking Xyrem for over five years. For both women, the medication had always been covered by their insurance companies. Yet for some unknown reason, when their doctors submitted their prescription-refill, both women received similar letters from their insurance companies (Cigna and Anthem) stating, “Coverage for the requested medication is denied because the medication does not meet the criteria of “medical necessity” under your description of benefits.” Both Cigna and Anthem also told the women that their prescription was “off-label” and therefore not covered for that reason, as well.

“Medical Necessity” Denials: Wrong At Best, Egregious At Worst

Jane’s Case: For eight years prior to Cigna’s denial, two of Jane’s treating physicians prescribed Xyrem and it successfully treated her neuropathy and incapacitating fatigue. Prior to taking Xyrem, Jane suffered “incapacitating fatigue, disabling pain, short term memory loss, cognitive decline and an inability to concentrate.” As a result of Xyrem, Jane’s quality of life significantly improved and Jane’s doctor stated that Jane had become “more alert and engaged in life and lived without the debilitating fatigue and pain caused by her neuropathy.” Despite Jane’s medical records clearly documenting the effectiveness Xyrem had on her pain and fatigue, as well as that the prescription was in accordance with the generally accepted standards of medical practice, Cigna denied Jane continued coverage. As a result, Jane started halving her dosage of Xyrem and ‘stock-piling’ it in an effort to prevent running out. Without the proper dosage, Jane’s suffering resumed and in fact increased, as a result of the stress she was under from the denial. Jane’s doctor wrote an appeal letter but Cigna denied that, too.

Mary’s Case: For five years prior to Anthem’s denial, Mary felt strongly that Xyrem had “completely changed her life.” Mary’s doctor wrote in her chart that Mary was “Quite tearful at the prospect of having it be discontinued. She uses the analogy of giving a blind person their site and then taking it away again.” Prior to Xyrem, Mary suffered overwhelming excessive daytime somnolence and was diagnosed with idiopathic hypersomnolence without cataplexy. Less than one month after starting treatment with Xyrem, Mary’s doctor reported, “She has had complete resolution of her prior “micro naps” and “black out spells”…Patient doing exceptionally well… Good energy, productive, feels well, mood is better overall…She is very fearful about stopping the Xyrem, because this is the most awake and able to function that she’s been in years.” Although Mary discontinued Xyrem when she became pregnant, after she gave birth, she and her doctor made the decision that Mary should resume taking Xyrem because her fatigue had become overwhelming again. When Mary tried to fill her prescription, Anthem denied coverage, despite having covered it for the previous five years. Mary’s doctor appealed the denial but Anthem denied that, too.

Is There Hope Against Insurance Companies? The Answer Is “YES.”

When Jane and Mary contacted our office, they were at their wits end and feeling hopeless because Xyrem costs an average of $13,000.00 out of pocket per month.

Kantor & Kantor appealed Cigna and Anthem’s denials on behalf of Jane and Mary. In our appeal letters, we pointed out the facts including: the community standard of treatment for Jane and Mary’s diagnoses; Jane and Mary’s lives prior to taking Xyrem and their lives after taking Xyrem; research articles; and the medical necessity of their prescription. Further, we informed Cigna and Anthem of what the U.S. Food and Drug Administration (“FDA”) states about prescribing medications for off-label usage. The FDA’s perspective on prescribing off-label is that once the FDA approves a drug, healthcare providers may prescribe the drug for an unapproved use when they judge that it is medically appropriate for their patient. In other words, if the physician who is treating the patient (not some random insurance company doctor who gets paid to deny) deems a medication is medically appropriate (aka: medically necessary), the doctor may then prescribe it, even if it is off-label.

Our appeal letters resulted in respective victories for Jane and Mary. Cigna and Anthem both overturned their denials and resumed coverage of Xyrem, for the next 365 days. After receiving the call from her doctor that Anthem approved Xyrem, Mary wrote to Kantor & Kantor to say,

“I just wanted to email before the day comes to an end to let you know how grateful I am that you are both helping me and that the [X]yrem was approved today. When I got in touch with you, I was feeling so hopeless that I would never be able to feel back to “normal” and just absolutely beaten down by the bureaucracy…disillusioned that Anthem could be allowed to rob me and my family my health, happiness, and well-being. This process has been horrible and frankly traumatic (before you both came along).”


At Kantor & Kantor we have a team of experienced attorneys who are all dedicated to obtaining the best possible result for our clients. If you or someone you know are being denied health insurance benefits by your insurer, please call for a free consultation at (877) 783-8686 or fill out our online form here: Kantor & Kantor, LLP. We understand and we can help!



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