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Health Insurance Denials- Myeloma
What health insurance denials do myeloma patients have to deal with? To put this another way, managing MM is expensive- even just the deductibles and co-pays. The last thing you need is for your health insurance company to deny a therapy that your oncologist ordered.
Further, if you manage your MM for years, chances are that you will have one or more denials to deal with. I had to deal with 5 of the 10 examples listed below.
My experience is to take a deep breath and work the problem.
What costs are myeloma patients usually denied by their health insurance?
Health insurance coverage for multiple myeloma patients varies depending on the insurer, policy, and specific treatments needed. However, some common costs that insurance may deny or partially cover include:
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Experimental or Off-Label Treatments – Some newer therapies, clinical trials, or drugs used off-label (not FDA-approved for myeloma but proven effective) may not be covered.
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High-Cost Specialty Drugs – Certain expensive medications, such as CAR-T cell therapy or monoclonal antibodies, may have limited coverage or high out-of-pocket costs.
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Stem Cell Transplants – Some policies may only cover autologous transplants (using the patient’s own cells) and not allogeneic transplants (using donor cells), or they may impose restrictions on the number of transplants allowed.
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Supportive Care Medications – Drugs for managing side effects (e.g., bone-strengthening agents, anti-nausea meds, or pain relief) might have limited coverage or require high co-pays.
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Home Health and Palliative Care – Insurance may deny or limit coverage for in-home nursing, physical therapy, or hospice services, depending on the policy.
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Travel and Lodging for Treatment – If a patient needs to travel to a specialized cancer center, insurance typically does not cover transportation, lodging, or meals.
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Nutritional Support – Special diets, supplements, or nutritional counseling are often not covered, despite their importance in maintaining strength during treatment.
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Second Opinions – Some policies may restrict coverage for consultations with specialists outside the provider network.
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Rehabilitation and Physical Therapy – Post-treatment rehab, including physical therapy to regain strength, may be denied or limited.
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Mental Health and Counseling – Psychological support, including therapy for dealing with cancer-related stress and anxiety, may not be fully covered.
Reasons for Health Insurance Claim Denials and How Often They Occur
Three examples from MM patients-
- I was denied pomalyst (pomalidomide) because I was “supposed” to try Revlimid first. I was pretty upset at the time because 2 doctors had recommended it over Revlimid for several reasons. The insurance company said Revlimid was cheaper so I had to try it and either fail by having disease progression or not be able to tolerate the side effects. Both happened within 6 weeks. Then I did fine with pomalidomide for a while.
- Another time I was denied a refill of a prescription they had already filled once that I required post Car-T. I had to pay for it out of pocket then 60 days later the study reimbursed me. 60 days after that, my appeal was approved and the denial overturned. Too little too late. But I didn’t have to pay for it.
- I had CAR-T denied by my employer sponsored insurance plan because it was “not a procedure covered in the policy”. I didn’t appeal it because I was switching to Medicare anyway and was told approval would be easier with Medicare. Other than that, I have had very few issues with insurance coverage.
Don’t get me started on evidence-based non-conventional therapies. When I use the term “non-conventional” I’m referring to all therapies that have not been FDA approved. Not being approved by the FDA is a probable reason for your health insurance to deny your claim.
Email me at David.PeopleBeatingCancer@gmail.com if you have questions about your own claims that have been denied by your health insurance.
Hang in there,
David Emerson
- MM Survivor
- MM Cancer Coach
- Director PeopleBeatingCancer
How do you appeal an insurance denial?
“People who appeal denials are later approved at least half of the time”
It is not uncommon for people undergoing cancer treatment to receive a denial from their health insurance plan. These denials may be the result of a simple administrative error, a missing form, incomplete information or an overlapping claim. The good news is people who appeal denials are later approved at least half of the time. So, when you learn of a denial, take a deep breath and try not to panic.
Call your health care provider’s office and speak with the finance department. In many cases, claims are denied due to an error when they were submitted. Ask the provider’s office to check whether there could be an error that may require them to reprocess the claim.
Your next call should be to your insurance company. Insurers have to provide a reason for any denial of a claim. Some claims may be denied if they are for a treatment that is deemed not medically appropriate or is excluded from the coverage plan…
If you’ve exhausted all appeals, ask your health care team about other treatments that would be covered by your insurance, or explore options for financial assistance through your care center, pharmaceutical companies or nonprofit organizations…
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