Major insurers are denying claims for patients in states with contested Congressional races. With President Trump training his fire on Big Insurance, this could shape up to be a consequential issue for voters as November approaches.
Writing in The Detroit News, Dr. Cara Leahy, a neurologist at a community hospital in rural Michigan, explains how Blue Cross Blue Shield won’t cover FDA-approved Alzheimer’s therapies for her patients.“Many of my patients want to try new Alzheimer's medicines that work best when started early. But I watch insurers either deny them coverage outright or subject them to months or years of reversals — approving a treatment, pulling it back and forcing patients off therapies that are working.
“These insurers behave as if Alzheimer’s can wait. It cannot Alzheimer’s progresses much like cancer. The cognitive loss it causes is irreversible. When caught early, patients have a narrow window to intervene, slow progression and preserve quality of life. Yet insurers routinely block access during this critical period.”Dr. Leahy tells the story of one of her patients, Lori, a 65-year old woman whom she diagnosed with early stage Alzheimer’s and treated with one of the approved therapies. Lori was still working at the time of her diagnosis, so her employer-sponsored insurance covered the treatment.
Although the treatment was helping Lori—the drugs are approved to slow the progression of disease—she soon had to retire. She lost her employer-sponsored insurance and turned to Blue Cross Blue Shield Michigan to get coverage so she could continue the treatment. Dr. Leahy describes what happened next as a nightmare.
“Lori and her family had hope, until Blue Cross Blue Shield extinguished it. Over less than two years, Blue Cross Blue Shield approved, denied, reinstated, paused, approved again and ultimately terminated Lori’s treatment — not because it stopped working or became unsafe, but because they no longer wanted to pay. Each coverage reversal meant irreversible cognitive decline lost to a disease that does not pause to wait for appeals or paperwork.”
According to Dr. Leahy, insurance companies routinely deny coverage for these treatments, claiming the Federal government deemed them “experimental”. This is based on their inclusion in Medicare’s Coverage with Evidence Development (CED) program, a decision made by the Biden administration to require that doctors enroll beneficiaries in a data-collection registry in order to obtain coverage.
“Private insurers point to the CED program, which Medicare has applied to no other FDA-approved medicines, to label Alzheimer’s treatments as “experimental” or “investigational” to justify their denials, even though the treatments have cleared the United States’ highest evidentiary bar for medicines. It is past time for Alzheimer’s treatments to graduate from this holding cell that enables insurers’ bad behavior. Until treatments are released from CED, insurance companies will continue denying coverage on this basis.”
The CED program hasn’t published any new information since it moved to restrict coverage for these drugs, and it doesn’t seem to serve a purpose at this stage other than to give big insurers cover to deny treatment claims.
You can read Dr. Leahy’s full op-ed in The Detroit News here.
