A 9-month-old boy with an aggressive brain tumor received a letter from his family’s insurance company explaining that treating the cancer would be too expensive and therefore “not medically necessary.”
‘Dear Connor Richardson,” the letter said, according to The Daily Beast, “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.”
Connor’s father — retired NYPD officer Wayne Richardson — told The Daily Beast’s Michael Daly that at 7 months old, his son had a frightening crying jag late one night. The baby’s eyes popped open, wide and staring.
“Not like a regular baby, like when somebody dies,” Richardson said.
Connor was diagnosed with a rare aggressive teratoid rhabdoid brain tumor that was blocking blood flow to his spine. Doctors removed the tumor, but the cancer returned.
St. Jude’s Children’s Hospital in Memphis, TN opted to place the baby on 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.
However, the family’s insurer has deemed 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.”
“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,” the letter explained. “This letter is your Initial Adverse Determination. This means we are denying your quest for coverage of the requested service(s).”
Then, in a bold-typed section, the company explained to Connor — as if he were his own child:
“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.”# p #11_16 # ad skipped = true #
Because the treatment is a clinical trial, it may not reverse the cancer’s growth. Therefore, HIP sees no reason to pay for it.
Fortunately for the Richardsons, St. Jude’s does not charge patients for medical treatment, said Daly, and even provides families with transportation to and from the hospital as well as food vouchers during their stay.
Wayne Richardson said that he believes St. Jude’s should be paid the denied funds, however, because it will aid the hospital on its mission to help children and fuel further research.
“You’re taking away from them and their research…because the insurance doesn’t want to pay,” he told Daly.
“Wayne plans to contest the denial, and the letter does tell him how to file an appeal,” Daly said. “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.”