A 9-month-old boy named Connor Richardson, who is currently battling an aggressive and rare form of brain cancer, received a letter from his family’s insurance company explaining that his current treatment would be too expensive to cover and therefore “not medically necessary.”
The letter reads:
October 11, 2017for: Inpatient Hospitalization to St. Jude Hospital from 10/4/2017-10/10/2017. We have determined that the service(s) are not medically necessary.
Dear Connor Richardson,
As HIP Health Plan of New York, we try hard to provide you with access to quality health care services that meet your needs. When we decide to deny coverage for treatment or service, we want to make sure you know why…
We look over the clinical and medical information given to us and check the criteria, guidelines and the rules of your health coverage policy to make our decision.
When we reviewed the information given to us about this request, we have decided to deny coverage of the following medical service(s) or item(s) that you or your provider asked for: Inpatient Hospitalization to St. Jude Hospital from 10/4/2017-10/10/2017. We have determined that the service(s) are not medically necessary.
This letter is your Initial Adverse Determination. This means we are denying your quest for coverage of the requested service(s).
According to The Daily Beast, the letter then offers the reason for the denial in a paragraph that is “in bold and further set off by quotation marks. The letter here speaks to Connor as if he were his own parent.”
“Your child is a 9 month old boy who was diagnosed with a high grade brain tumor. Your child was treated with surgical removal of his tumor at Stony brook Hospital. After your son was discharged you enrolled him in a clinical trial at St. Jude’s hospital. The principal investigator has requested medications including methotrexate, cisplatin, cyclophosphamide, vincristine in combination with an investigational medication, alisertib. This combination of medications is not the standard of care for this type of cancer, and is considered experimental and investigational at this time, as evidence-based guidelines do not exist to confirm its effectiveness for his brain tumor. Therefore, this request for clinical trial treatment at St. Jude’s hospital is not medically necessary and is denied.”
The letter adds:
If you decide to have this service, you may have to pay it yourself.
Connor’s father, retired NYPD officer Wayne Richardson, told The Daily Beast’s Michael Daly that at 7 months old, his son was diagnosed with a rare aggressive teratoid rhabdoid brain tumor that was blocking blood flow to his spine. Doctors removed the tumor, but
Doctors removed the tumor, but the cancer returned.
Doctors at St. Jude’s Children’s Hospital in Memphis, TN treated the baby with a combination of four drugs plus an experimental medication in a desperate bid to save his life.
“He’ll die if you don’t do it,” said Richardson.
That’s when the family’s insurer sent the letter addressed to the baby, deeming that the lifesaving treatment is “not medically necessary” and warned Connor, “If you decide to have this service you may have to pay it yourself.”
The Daily Beast adds:
Fortunately for Connor, St. Jude is that rare medical institution that offers its services at no charge, even supplying patients and their families with transportation and food vouchers. Connor has embarked on his chemotherapy with no cause for his family to worry about the expense.
But Connor’s family understands that the payments the insurance company is denying would otherwise support St. Jude.
“You’re taking away from them and their research… because the insurance doesn’t want to pay,” Wayne said.
Wayne plans to contest the denial, and the letter does tell him how to file an appeal. Meantime, the insurance company will not pay for the chance to save Connor’s life. And the money the company saves will go in its coffers rather than toward treating and maybe curing catastrophically sick kids.