Whether you agree or disagree that private insurance and Medicare should always pay for every necessary multiple myeloma-related medical procedure or treatment, it’s clear that they don’t always.

The key word here is “necessary.”  The insurance company or Medicare may not agree with what you and your doctor feel is necessary.

The example I used in last week’s column ^[1] illustrates this perfectly. Although Revlimid ^[2] (lenalidomide) is not yet approved by the U.S. Food and Drug Administration (FDA) as an initial treatment for multiple myeloma, it is often prescribed for newly diagnosed patients.

At first, insurance companies commonly refused to pay for Revlimid use in newly diagnosed patients.  But over the past five years, so many doctors have prescribed the drug that it has become customary for insurance companies to cover the prescription.

Customary, but not a guarantee.  Because the vast majority of U.S. insurance companies have the right to refuse payment for drugs that aren’t FDA approved for a particular application, this issue still comes up from time to time.

Chances are an appeal will work in this case—but not always—making this a perfect example of how a patient, or patient’s physician, should always clear the use of any expensive medication or procedure with their insurance company or Medicare before proceeding.

OK.  We have established that insurance companies sometimes refuse to pay for all or part of a drug or procedure on the grounds that it is “experimental”—code for “not FDA approved.”

But sometimes they can deny coverage based on arbitrary rules.  A perfect example of this is Medicare’s policy of only paying for a single stem cell transplant.

Is this rule rigid and outdated?  Probably.  But understanding this rule can help a multiple myeloma patient save tens of thousands of dollars.

I know several patients who decided to transplant in their early 60s, with the thought that they would then be entitled to a second transplant, paid for by Medicare, after they turned 65.

Europeans and Canadians are familiar with arbitrary coverage limitations based on efficacy and cost.  But many Americans fear this type of restriction, even though it already exists in our health care system.

This is one of the reasons the newly enacted Patient Protection and Affordable Care Act, often referred to as “Obama Care,” is still opposed by a large minority of American voters.

I bet you are thinking, “Great!  Now Pat is going to get into the controversial political stuff he promised us last week!”

I hate to disappoint you, but not so fast!  I’ll get to the all-important question, “Is treatment for multiple myeloma a privilege or a right?” next week.

For now, I would like to provide you with a list of a few insurance-related tips that have helped me over the years:

1. Review your policy. Spend an hour or so trying to read and understand the fine print.
2. Meet with your insurance agent. Keep him updated. Call with questions or when you feel that you aren't being taken seriously by your insurance company. My agent took the time to meet with me after my initial diagnosis. He helped me understand my policy and successfully fight the insurance company when I was denied coverage for my early chemotherapy and later my stem cell harvest.
3. Enlist your doctor’s help. I find it helpful to get to know his or her nurse. Be polite and courteous. Develop a relationship. Most health care professionals are in the business because they want to help the patient.
4. Non-profit groups like the Patient Advocate Foundation ^[3] are often available to help.
5. Know the law. What consumer protections are offered by your state? Does your state have an insurance review board?
6. Don't give up! A recent Kaiser Family Foundation study found that over 50 percent of all denied claims were later paid.
7. Patients who continue to press, even after a second or third denial, are often successful.  I even know patients who appealed clearly-stated rules and policies and won!
8. Keep good records, and be persistent!

You shouldn't have to do all of this extra work. It isn't fair!  But it is one way to keep your health care costs down.

Next week will be devoted to the billion dollar philosophical question:  Is treatment for multiple myeloma a privilege or a right?

Feel good and keep smiling!  Pat