En esta noticia
A 26-year-old woman who received a heart transplant was left without coverage for her anti-rejection medication after her health insurance stopped paying for it. “I did not know what else to do,” Payton Herres said, who posted her case on social media and received help from an unexpected source: businessman Mark Cuban.
Elevance Health, Herres’s insurer, informed her last year that it would stop covering everolimus, the drug she has taken since she was a preteen.
What happened to the young transplant patient’s health coverage?
Herres received her heart transplant at age 11, when she was a preteen, and a year later began taking everolimus, the generic version of Novartis’s Zortress, to prevent organ rejection. The treatment is lifelong.
When her insurer stopped the coverage, she posted her story on Facebook. “I did not know what else to do,” she later explained in an interview with the U.S. outlet MarketWatch. The post went viral, and a day later, coverage was restored, although with a much higher charge: from paying $180 to $1,000 for each 90-day supply.
How did Mark Cuban intervene, and what can a patient do after a denial?
The story reached Mark Cuban Cost Plus Drug Company, the pharmacy founded by the businessman, after other users tagged him on social media. “This is more than incredible. They approve and pay for the heart transplant. They deny the generic anti-rejection medication,” Cuban wrote on LinkedIn after learning about the case. His company began to provide her with the medication for about $300 every 90 days, with the support of a nonprofit foundation.
If coverage is denied, every patient has the right to request an internal review from their insurer and, if that does not succeed, to request an external review by an independent third party. They can also file a complaint with their state’s insurance regulator.
Steps to appeal a health coverage denial
- Request the exact reason for the denial in writing
- Gather medical records and documentation supporting the treatment
- Request an internal review from the insurer
- If necessary, request an independent external review
- File a complaint with the state insurance regulator if the appeal does not succeed
Having an emergency fund also helps maintain access to treatment while an appeal is being resolved, since medical expenses are one of the main causes of household debt in the United States.