Holding pattern at home for weeks while waiting for the response to Dr. Mayer’s appeal for double dosage of Humira. Idle days try to read until stomach cramps then hit the bowl, video games if I have a rush of energy, otherwise lie on the couch with a movie on in the background.

Why don’t you eat something?

I’m not hungry enough yet.

It’s not bad.

Tasteless, odorless crud. You don’t know any better.

Until the evening key jingle in our apartment door, slightly embarrassed by my state of inactivity. “Here’s the response from the insurance company, finally…” said mom as she put down her bags with notepads and preschool craft supplies to open the envelope, “Jesus… these assholes.” She finished reading and handed the me the headered letter, I sat up to read:

 

UnitedHealthcare Services, Inc. on behalf of Oxford has completed its review of your request to appeal the decision to deny Humira 40mg.

We have considered the information submitted in support of your appeal. Based upon the review of all available information and the terms of your plan, our Medical Director has decided to approve coverage for two cartons per month for three months and to uphold the initial

adverse determination for four cartons per month (eight injections). The services remain denied because this is a patient with Crohn’s Disease for whom 8 injections per month of Humira 40mg is requested. The Manufacturer recommended dose of Humira for the treatment of Crohn’s Disease is 160mg initially at week 0, 80mg at week 2, followed by a maintenance dose of 40 mg every other week beginning at week 4. While Micromedex reports studies which include patients randomized to Humira 40mg per week, there are insufficient peer review studies to show the safety and efficacy of ongoing, long-term maintenance therapy with Humira at 40mg per week and no studies listed which show the safety and efficacy of Humira given at 80mg per week on an ongoing basis. Clinical studies have not evaluated the use of Humira beyond 1 year. The Medical Director/Consultant who participated in this appeal review is a Physician whose specialty is internal medicine and emergency medicine. This is the final adverse determination of this matter under New York law for purposes of the external appeal statute. Enclosed is an explanation of member appeal rights.

Sincerely,

Mary Jo Conetta, Coordinator HCS

 

“Damn.”

“First they raise the price without telling us, then they fight with us tooth and nail over increasing the dosage.”

“And they kept the reviewing physician anonymous, who is either a Medical Director or a Consultant? Seems like two very different jobs.”

“I’m sure it means they’re just paying a doctor kickbacks to provide medical grounds for coverage denial. Of course he wants to be anonymous.”

“Why would a doctor who probably has a conflict of interest and who’s never met or examined me get final say over my doctor whose job it is to get me healthy?”

“It’s disgusting. I’m going to follow up with our insurance advocate at work, maybe we’ll see if we can get anyone to listen in city government.”  

“Sorry it’s such a headache.”

“Don’t be sorry, this is a bunch of nonsense, but I think it’s good for you to know what we’re dealing with.”

“Well don’t go too crazy. Probably don’t want to be on these potent immunosuppressants for my whole life anyways, cancer is one of the long-term side effects.”

“Don’t worry about that. Our first goal is just to get you healthy, and then we can think about long-term stuff later. How are you feeling today?”

“Trouble sleeping through the morning, just been dozing on the couch mostly.”

“Well, your follow-up appointment is next week, so we’ll see what Dr. Mayer thinks the next steps are.”

Wish for remission, scared of the scalpel, maybe unavoidable and no guarantees.

“Are you hungry?”

“Not really.”

“How about just a little bit of plain pasta and a bite of greens?”

I’d be dead without parents, complete dependence. 

“Yeah, that sounds good.”

“Okay, let me get that started.”

Head back down.

I demolished five saucers with one rocket!

Not bad, for an amateur.

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