Ramy Sedhom, MD, a medical oncologist and a palliative care physician at Penn Medicine Princeton Health in Plainsboro, New Jersey, will always wonder if prior authorization refusals led to his patient's death.
The patient had advanced gastric cancer and the insurer initially denied a PET scan to rule out metastatic disease. When the scan was eventually allowed, it revealed that the cancer had spread.
Standard treatment would have been difficult for the patient, an older individual with comorbidities. But Sedhom knew that a European study had reported equal efficacy and fewer side effects with a reduced chemotherapy regimen, and he thought that was the best approach in this situation.
The insurer disagreed with Sedhom's decision and, while the two argued, the patient's symptoms worsened. He was admitted to the hospital, where he experienced a decline in function, common for older patients. "Long story short, he was never able to seek treatment and then transitioned to hospice," Sedhom said. "It was one of those situations where there was a 3- to 4-week delay in what should have been standard care."
That course of events is not an outlier but everyday life for physicians trying to navigate insurers' prior authorization rules before they can treat their patients.
