• I have been selected for a clinical trial for recurring PPC, and my insurance company is refusing to pay their part. Anyone resolve this?

    Asked by Carolscheff on Wednesday, September 26, 2012

    I have been selected for a clinical trial for recurring PPC, and my insurance company is refusing to pay their part. Anyone resolve this?

    Medicare and the trial sponsors pay for some , but Anthem will not pay for trials or studies .

    9 Answers from the Community

    9 answers
    • teddyfuzz's Avatar

      It seems to me that the trial sponsors should be paying for the whole thing. Sometimes you can get the insurance company to pay things that are "medically necessary" by writing a well-written grievance letter. My insurance company (Blue Shield) originally denied my BRCA testing but then allowed it after I sent them a letter explaining why the test was medically necessary. Good luck and I hope you are able to get this resolved!

      almost 6 years ago
    • BuckeyeShelby's Avatar
      BuckeyeShelby (Best Answer!)

      I work in the health insurance industry. Two pieces of info which might be helpful. I know that every one of our plans (and our groups are all self-funded) include language excluding experimental procedures. However, all insurance companies do have to have an appeals process. If you call the customer service line of your company, one of the reps should be able to walk you through the process of how to file an appeal. I would suggest getting your doctor's help as far as letters of medical necessity and why he/she thinks this is the best course of treatment for you. It may still be denied, but you definitely want to explore every avenue available. And remember, those reps on the phone have no vested interest in denying your request. I audit phone calls for my company -- those types of decisions are NOT made in customer service. And don't let them be mean or rude to you -- ask for a supervisor if they get nasty. Our CS manager views rudeness as grounds for termination w/our reps. Good luck!

      almost 6 years ago
    • nancyjac's Avatar

      Generally, commercial insurance companies do not cover experimental procedures or medications, so I'm not sure what "their part" would be. If you are also have standard treatment outside of the trial, that should be covered by Medicare + your supplemental insurance.

      almost 6 years ago
    • Harry's Avatar

      BuckeyeShelby's suggestions are good. But, I have found, when dealing with all types of companies, that it is a good idea to keep the following in mind:

      1. The person who you first talk to probably doesn't have a lot of leeway in how they handle your situation. The magic words are, "I want to speak to your supervisor." Don't accept, "No." Any refusal to transfer you immediately to a supevisor is grounds for escalation. If you do get through to a supervisor, try to reasonably explain, again, what you want and see if that works. If not, escalate.

      2. Escalation. If you hit a brick wall, then go to the top. A little on-line research should get you the name, location, and phone number, of the company's CEO. Probably not their direct line but, at least, the phone number of their main office. Call that number and ask for the CEO by name. You will probably get the Vice President in Charge of Handling Obnoxious Customers. That person should be able to help. Again, explain what you want reasonably. It may take a day or so, the VP will need to "investigate," but if there is a way to fix it they should be able to help.

      almost 6 years ago
    • Lavonne's Avatar

      My sister in law has had problems with this also. If your insurance will not pay see if the if the place doing the clinical trial has any financial assistance programs

      almost 6 years ago
    • Carol-Charlie's Avatar

      Ask your oncologist if he/she is aware of other ways to get this paid for... See if they'll work with you on this. I know I feared my age would keep me from treatment when I was diagnosed at 62....... I had no problems from Blue Cross/Blue Shield... But my treatment had just come off trial status the month before my diagnosis. I'm 69 now and cancer free. Please keep us posted. I'd certainly file a protest... you might even want to go public by calling a TV station seeking their assistance in fighting for your rights of treatment from Anthem.

      almost 6 years ago
    • Rachel702's Avatar


      Follow the link to the see if the clinical is approved. If your clinical trial is approved then per state law, they must pay. Hope this helps.

      almost 6 years ago
    • LuvinSis' Avatar

      You received some excellent suggestions. I also worked in the insurance industry and agree you should escalate to the next level when you hit a wall. I always recommend being direct but very nice to the rep. Although they have no decision making authority, they can help you get to the supervisor/next level. "You've been helpful, maybe you can connect me to someone who is a supervisor or manager so I can pursue it further" If people are too rude to the rep I've seen calls don't go where they should. Also ask the staff offering the experimental treatment if they have patient advocates that work with insurance companies.

      almost 6 years ago
    • Marcy1's Avatar

      My mother participated in a phase 3 study for ovarian cancer. The drug company paid whatever costs were not covered my Medicare. You might want to ask.

      almost 6 years ago

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