Overturning A Denial Even After All Appeal Levels Are Exhausted

After previously telling my story regarding my treatment denial, there was an outpouring of kind words and emails. Thank you all. I was reminded by a good friend that I should take the time to give listeners an update, so people do not worry or wonder.

So I’m pleased to share that after considerable effort, I received a call from the member services department of my insurance provider. They have decided to “reconsider” my previous denial and have now overturned it, granting approval for my treatment, effective immediately.

This has allowed me to successfully complete my treatment and resume services as of this past week.

This experience has been quite eye-opening, and hopefully offers valuable insights for others facing similar challenges. Although this resolution required significant effort and may not be feasible in every case, it demonstrates the potential for success even when navigating significant complexities with insurance denials.

The breakthrough in my situation came as a result of pushing the boundaries beyond the traditional “two levels of appeal” process. Initially, I launched a significant outreach campaign on LinkedIn, strategically tagging the medical director who reviewed my case and the insurance provider. These moves garnered considerable attention, including from employees at BCBS and CVS Caremark. It was evident that the visibility of my case was impacting public image and maybe the compassion of some of their employees. Insurance companies, like other firms, are highly sensitive to negative press from their members and its potential effects on their future business.

In addition to the social media campaign, an attorney from my husband’s employer filed a formal complaint against BCBS of Maryland and CVS Caremark with the Attorney General’s office in Maryland. This formal complaint prompted a follow-up from the insurance company seeking to “better understand” the situation.

During this interaction, we reminded BCBS that all phone calls were recorded, as per their policy, and suggested they review the numerous recordings that documented our discussions with their internal team members.

Furthermore, I received news last week that my submission for financial assistance to Merck, the drug maker for Keytruda, was approved. As a result, I am now eligible for one of their programs that will cover the out-of-pocket costs for my infusion treatments for the remainder of the year.

This additional support significantly alleviates the financial burden associated with my treatments.

I share this update to encourage anyone who finds themselves in a similar situation not to give up simply because an insurance company has denied a claim. There are ways to navigate and challenge what may seem like an impenetrable system.

Persistence, strategic communication, and leveraging available resources can make a significant difference.

Lastly, again, I want to express my gratitude to everyone who reached out with advice and support during this process. Your assistance and encouragement were invaluable in achieving this positive outcome.