Denial of coverage

The 9-month-old son of a retired NYPD officer allegedly received a letter from the family’s insurance company recently, explaining that the clinical trial he was enrolled in to treat aggressive brain cancer was “not medically necessary,” and therefore would not be covered by the provider.

The family’s plight began two months ago when Connor Richardson, then 7 months old, was diagnosed with a teratoid rhabdoid tumor, The Daily Beast reported. He underwent two major surgeries at Stony Brook University Hospital in New York to remove the tumor, but follow up exams at St. Jude Children’s Research Hospital in Memphis discovered the tumor had returned and the cancer spread to his spine.

While St. Jude provides free care to its patients, Richardson’s father, Wayne, told The Daily Beast that they were shocked to receive a letter from HIP health insurance dated Oct. 11 and addressed to their baby. Wayne said the first thing he noticed at the top of the alleged letter were the notes “Type of Review: Prospective” and “Type of Denial: Medical Necessity.”

 “The principal investigator has requested medications including methotrexate, cisplatin, cyclophosphamide, vincristine in combination with an investigational medication, alisertib,” the alleged letter purportedly said. “This combination of medications is not the standard of care for this type of cancer, and is considered experimental and investigational at this time, as evidence-based guidelines do not exist to confirm its effectiveness for his brain tumor. Therefore, this request for clinical trial treatment at St. Jude’s hospital is not medically necessary and is denied.”

Wayne told The Daily Beast that while as a parent, you don’t care what it costs to heal your child, the concern is that the insurers are denying payment to a hospital that focuses on children’s research. He plans to contest the denial, and said without the treatment, Connor would die.

“You’re taking away from them and their research … because the insurance doesn’t want to pay,” he told The Daily Beast.

Connor has been receiving treatment at St. Jude’s since the end of September. A GoFundMe page has been keeping supporters updated on his progress.

http://www.foxnews.com/health/2017/10/19/insurer-allegedly-sends-coverage-denial-letter-to-9-month-old-with-brain-cancer.html