Elim Garak
Veteran
When insurance twice refused to cover a nearly $800,000-a-year drug that Paxton Pope’s doctor believed could dramatically reduce his frequent seizures, his family initially braced for a serious medical setback.
Then the Popes, of Davidson, North Carolina, learned about a little-known provision in the Affordable Care Act that allows asking an outside state-run panel to review the insurer’s decision — a move that led to the denial ultimately being overturned.
When insurance twice refused to cover a nearly $800,000-a-year drug that Paxton Pope’s doctor believed could dramatically reduce his frequent seizures, his family initially braced for a serious medical setback.
Then the Popes, of Davidson, North Carolina, learned about a little-known provision in the Affordable Care Act that allows asking an outside state-run panel to review the insurer’s decision — a move that led to the denial ultimately being overturned.
In the few months since then, access to the drug has already transformed the 13-year-old’s life, according to his mother, Maggie Pope. Paxton went from as many as 12 seizures an hour to about eight a day, she said, and he’s regaining skills he had started to lose, like holding conversations and telling them what he’s reading in school. For the first time, he’s able to play on his school’s flag football team.
“I was just over the moon,” Maggie Pope said. “I looked over at him, and he was just smiling. I said, ‘Paxton, did you know you were having less seizures?’ And he just kind of shook his head, ‘Yeah.’”
The denial was overturned by the North Carolina Department of Insurance, a state agency that oversees health insurers and helps patients challenge denied claims.
Every state has some form of insurance department or commission, although what programs they offer and the amount of resources they have can vary. Experts say that while most patients don’t know these agencies exist, they can guide individuals or families through an additional step beyond the insurer’s internal appeals process: an external review.
Under federal law, if a doctor says a treatment is medically necessary but an insurer still denies it, requesting an external review sends the case to an independent panel, which assigns it to a doctor to review the claim and issue a binding decision.
“They’re a well-kept secret,” said Michele Johnson, executive director of the Tennessee Justice Center, a law firm and nonprofit advocacy group that helps people dispute medical bills. “I think it’s definitely worth trying, and get doctors to help fight for you, because, of course, the doctor’s opinion is going to make a huge difference.”
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