Prior Authorization

Is a pain in the you-know-where!

It finally happened to me.

An insurer denied an asthma nebulizer medicine I’ve used for thirty years. I am sick as a dog with asthmatic bronchitis, and have been for three weeks. I ran out of a crucial medicine to dilate my airways.

The Medicare explanation given — and you’ll love this — is that I’m “still living at home and not in a skilled nursing facility.” WHAT? What in the world has LOCATION to do with covering a medicine? Not like it’s radiation therapy!

As it turns out, after my initial outrage, Medicare defines nebulizer solutions as DME, durable medical equipment. Let me be the first to point out nebulizer solutions are MEDICATIONS delivered by a machine that aerosolizes them. The machine is the piece of durable medical equipment. Duh.

Oh well. All that was needed was for the pharmacy to get a copy of my Medicare Part B card. Now this will be covered.

I’ve worked in health insurance for nearly thirty-five years and know why PA, prior authorizations, are necessary. Back in the dark ages when I started, hysterectomies and scheduled C-sections were being done at an alarming rate. They are safe, but still have deaths associated with them. In part due to costs, but also for patient safety, health insurance companies started asking physicians to prove medical need for these procedures.

I spoke to a lot of unhappy doctors in those days who’d never had anyone look over their shoulder. I learned fast the good docs didn’t argue. Calm and thoughtful, they presented their case. And often I overturned the denial because it made medical sense and they had other info not in the records. The bad docs argued, screamed, and swore like sailors.

“How dare you?” was the most common phrase.

The irony is it’s how I diagnosed my own medical issue. Turned out years later, when I had my hysterectomy, the insurance algorithm and I had been right. Endometriosis of the uterus muscle, called adenomyosis. Only solution once childbearing is done is a hysterectomy.

Unfortunately, the beast named PA has grown into a monster. Every company wants a PA on everything it seems. My nebulizer meds cost $20. It has to be more expensive to deny coverage, run the system and pay the people to deny it, send out notices (and with Medicare, they will still send a ream of paper in the mail besides the email) and then deal with the multitude of appeals.

I’m surprised the pharmacy didn’t already know this, but a lot of pharmacists are young, new and overworked.

PA now interferes with good care. A young lady we know has been diagnosed with aggressive form Stage III breast cancer. Her doctor ordered a PET scan. Now, PET scans are more expensive than CT scans and bone scans. But the information they give the oncologist is like a bone scan combined with a CT-scan. And even more, as PET scanning can find areas of early soft tissue metastasis like lymph nodes that neither a bone scan or CT-scan would catch.

I am shocked and saddened. Why has it gone this far? Health insurance is nickel and diming itself to death, and this may actually kill some patients. It’s not necessary to PA a nebulizer solution that costs $20.

A million dollar transplant? You bet it needs to be reviewed.

I would argue with a cancer diagnosis, we don’t need to PA the first PET scan. If they try to do one PET scan a week, then yeah, that needs to be questioned. But cancer does funny things. This young woman deserves far better from her insurance company.

She’s already started chemo, then will have surgery plus radiation followed by years of hormone therapy. Do you have any idea how much this is all going to cost? I do. Hundreds of thousands of dollars, upwards of a million or more.

Compare that to a single PET scan at around $5,000. The cost for the scan is minuscule. It will guide her care. It may even change her care pathway and make it cheaper. Imagine that. A cost-savings.

I wish I was much younger and could work for RFK Jr. He’s got the right ideas. Review stuff like drugs and food additives properly. Don’t approve something that hasn’t had enough research. (PET scans have)

Elon and DOGE also have the right idea. I have seen so much medical FWA, fraud, waste and abuse, it’s not funny. At Anthem, we saw a spike in highly costly testosterone shots in the L.A. area being given to men, in clinics with doctors who oddly all had Russian surnames.

We investigated. Turned out the Russian mob had set up clinics and paid men off the streets to “get a shot” they never received. But they had to give their insurance or Medicaid/Medicare card numbers.

I never liked the consolidation of health insurers. They are just too big and unresponsive now. Same with government health programs. Massive unrestrained bureaucracies where the left hand doesn’t even know the right hand exists.

If you get denied, don’t get mad. (even though I know you will) Investigate the matter online. I should have. I could have easily found out the nebulizer meds are under Part B if I’d bothered to google it.

But I’m sick and struggling to breathe. Most people filing health insurance claims ARE ill. Thankfully, the wonderful gal who does the PA for my doctor’s office quickly identified the problem. Not every doctor’s office has a Kelly, though.

I plan to write a future article on how to file and write an appeal, and try to get your denial overturned.

It doesn’t always work, though. Despite my endocrinologist speaking to the doctor (who he deemed a bit of an idiot) at the insurance company, Medicare won’t pay for my non-formulary thyroid medication. It costs me $400 a month. I have no thyroid. It’s the only brand that works, after multiple tries with generics and cheaper brand names.

But like I said before, Medicare doesn’t care!