experience with seeking insurance approval for more than one first level treatment---recent denial of a new treatment

[bwpickard]

My husband was diagnosed with inoperable HCC with portal vein involvement March 2019 and treated with Linvema and Y90 that killed the tumor in the portal vein and shrunk the main tumor. He has other small nodules. January scans showed live tumor around the rim of the dead main tumor and smaller ones had started growing. Switched to Opdivo, had repeat Y90, but his AFP which was 64 at its highest and dropped to normal started increasing to over 100-- Scans repeated and show smaller tumors still slowly growing, all confined to liver so unclear why AFP increasing. Liver function remains good. Insurance denied new treatment of Avastin/Tecentriq saying it's a first level treatment and we are on 3rd level. Approved Sorafenib (also first level treatment?) which MD is combining with continued Opdivo. Question re first level treatment and insurance companies as this is a new treatment that wasn't available before. Has anyone else run into insurance denials? Are you only able to have one first level treatment if there are other first level treatments available--Sorafenib is a first level also so I am unclear on this and want to consider appealing without delaying treatment but want to know if others have had experience with this. Doesn't qualify for the clinical trial that is still going on with Avastin/Tecentriq because of having been on a systemic med. Any help, suggestions appreciated. Insurance is BCBS.

[spazure Caregiver]

Soooo BCBS was in the news - somewhat recently - for denying claims they shouldn’t.

I would recommend appealing, honestly, because it’s disgusting that people sitting behind a desk think they know better than the doctors actually treating your husband.

[andersoncathl Caregiver]

I'm very sorry you are having to deal with this. I think it is appalling that they denied it but I sometimes think they do this just because they don't expect you to appeal and if you do, you may get approved. Again, I think this is awful because I know you are no doubt tired emotionally and physically and shouldn't have to appeal. Seems to me that something different (whether first level or not) may work for your husband. Why not be allowed to try it?? Best of luck to you both.

[AndreaWilson_Founder Partner Editor Caregiver]

If you still need Lenvima, please email me. There are Patient Assistance Programs (PAPs) for patients available and Lenvima has one.

~Andrea, Blue Faery Founder & President

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Lenvima (lenvatinib)*

Drug company: Eisai

Phone: [phone]

Link: eisaireimbursement.com/hcp/...

[bwpickard Caregiver]

Thankyou for your responses. Discussed appeal with oncologist who wants to give Nexavar with Opdivo a try first. MD diligent with doing scans every 2 months and if Nexavar doesn't work, he said may try to get Avastin approved with Opdivo or go directly to drug manufacturer for compassionate approval. My husband is only on 1/2 dose of Nexavar to minimize side effects this med well known for but is having some mild ones so MD holding at this dose right now. His AFP dropped from 172 to 88 after 10 days though MD said he doesn't think AFP provides significant info in my husband's case. This forum is such a blessing! I have read through several other stories very similar to my husband's and find hope and encouragement and am encouraging him to read and join as he could use a peer group. Thankyou!

[AndreaWilson_Founder Partner Editor Caregiver]

Don't ever hesitate to reach out. ~Andrea

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