When treatment can't wait for coverage

terrell smith

Insurance would pay for the standard treatment for Terrell Smith’s glioblastoma multiforme, the most common and aggressive of the primary brain tumors.

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Unfortunately, Smith’s egg-sized tumors were unresponsive to the standard drug, designed to interfere with cell growth. The star-shaped tumors kept growing, worsening his headaches, contributing to the personality changes that had brought him to seek diagnosis in the first place.;

His doctor at Emory Winship Cancer Institute, David Lawson (pictured at right), wanted to try infusions of bevacizumab, a then-new drug that works by cutting off tumors’ blood supply. The drug had already been approved by the FDA for use in patients with advanced lung, colon, or breast cancer, and some studies had shown that it also worked against glioblastoma multiforme. Indeed, after a few weeks of bevacizumab infusion, Smith’s tumors began to shrink.

The insurance company denied the claim, however. Without FDA approval for its use in brain cancer, the drug was deemed medically unnecessary. Nor would Medicare pay. Smith had been delighted with his improvement, but now his stress levels shot up. Each infusion cost $11,000, and he had already had seven.He was on disability. How could he possibly afford this?

         
  david lawson  

 David Lawson (pictured at left), wanted to try infusions of bevacizumab, a then-new drug that works by cutting off tumors’ blood supply. The drug had already been approved by the FDA for use in patients with advanced lung, colon, or breast cancer, and some studies had shown that it also worked against glioblastoma multiforme. Indeed, after a few weeks of bevacizumab infusion, Smith’s tumors began to shrink. 


 
         


Emory told him not to worry; discussions were under way with Genentech, the maker of the drug, about accepting Smith in a program in which the company would cover the drug’s cost. And if it didn’t, then Emory University Hospital Midtown, which handles billing for Emory Winship’s infusion center, would figure out a way to get this paid for or would cover it. The important thing was that he get the treatment he needed.

Two months later, Genentech said yes. So, suddenly, did the insurance company. The following week, the drug was approved for use in patients with Smith’s type of brain tumor (the same kind suffered by the late U.S. Senator Ted Kennedy). Medicare also agreed to pay. Emory had just been a little ahead of the game—and willing to pay if need be. It’s been more than two years since Smith’s cancer was diagnosed. He is doing well.




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