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Insurer reverses course on treatment

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By STEVE ANDREWS

sandrews@wfla.com

Published: June 23, 2009

Patricia Zimmerman wondered what hit her.

In September, a doctor diagnosed the 47-year-old Vero Beach resident with multiple myeloma, a cancer that develops in the marrow and expands to the bone.

"It started out with a simple backache," Zimmerman said.

In October, she was referred to the H. Lee Moffitt Cancer Center & Research Institute in Tampa. Chemotherapy started in December. Plans were in the works for a stem cell transplant. Two donors were found.

"I had Blue Cross Blue Shield coverage the whole time," Zimmerman said. "They took care of all that testing."

On her way to the Moffitt Cancer Center in late May for chemotherapy and the transplant, all that changed.

"We were 50 miles from Tampa and Moffitt called us and told us, 'Turn around and go home. It's been denied. The insurance has denied it,'" Zimmerman said.

Zimmerman and her sister showed up at Moffitt the next day, May 27, but the story remained the same: Blue Cross Blue Shield of Florida denied coverage.

"On Jan. 19, they had approved every single thing, which was the medicine, the transplant, the whole bit," Zimmerman's sister, Wanda Watson, said.

According to a letter to Zimmerman from Blue Cross Blue Shield of Florida, the insurance company reviewed Moffitt's request for a stem cell transplant and denied it because the "transplant must be performed in a clinical trial."

Moffitt estimates the stem cell transplant that Zimmerman needed costs about $450,000.

Before heading home for Vero Beach, a panicked and angry Zimmerman contacted News Channel 8.

"My nerves are so gone right now," Zimmerman said. "I've been paying $700 a month basically to get the insurance that I thought was covering everything."

Though there is potential for denial on every request, a patient access coordinator in the cancer center's blood and marrow transplant program estimates 7 percent of patients are denied, said Moffitt spokeswoman Patty Kim.

Claudio Anasetti, chief of Moffitt's Blood and Marrow Transplant Program, says there is much confusion in the insurance industry about transplants and clinical trials.

"They try to minimize the risk and cost; they are for-profit organizations," Anasetti said. "That, for the most part, guides their decisions."

Within five minutes of receiving an e-mail from News Channel 8 asking why it had denied Zimmerman's treatment, Blue Cross Blue Shield spokesman John Herbkersman responded, saying he had sent the questions to the agency's critical inquiries unit.

Less than 48 hours later, Herbkersman called.

"Blue Cross Blue Shield will provide coverage for the transplant; someone is on the phone with Patricia Zimmerman telling her the news," he said.

So why did Blue Cross first deny the coverage?

"We are constantly re-evaluating our decisions, and it just so happened we were re-evaluating this one," Herbkersman said. "We have provided coverage for her in the past and will continue to do so."

Zimmerman checked into Moffitt on June 11. Chemotherapy that started the next day left her drained and nauseated. The transplant performed Wednesday left her with new stem cells, a feeling of hope and a dose of reality.

"I know deep in my heart why it was changed, why they changed their minds, and it was partly from the interview that we did with you," Zimmerman said. "They didn't want to look bad."

By Sunday, Watson said, Zimmerman developed nausea and a fever that ran as high as 103.8 degrees.

"I keep trying to reassure her that it will turn around, but somehow I don't believe I have convinced her," Watson said.

News Channel 8 reporter Steve Andrews can be reached at (813) 221-5779.

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