Local opinion: Dealing with both cancer and prior authorizations can be unhealthy

Accessing care while dealing with a cancer shouldn’t be hard. Even as a retired RN with the support of a retired physician spouse, I found appeals and prior authorization overwhelming. How does someone without a medical background deal with the bureaucracy of the healthcare system?

Imagine needing a mastectomy, a significant body imaging change, and then having your insurance company tell you the only type of reconstruction they are willing to cover — their choice for your body. I wanted a DEIP reconstruction.

There was only one trained surgeon in town at that time, and he was out-of-network. The opposition and obstacles that I dealt with as I appealed the denied claim for this out-of-network surgeon were overwhelming. I was unable to function. My phone calls to numerous organizations over weeks and weeks were exhausting. They provoked panic, dread, horror, and astounding fear and anxiety. My tears and rage were intertwined daily. My perseverance and ceaseless calls, letters, forms, and discussions finally won my appeal.

None of this was healthy — neither physically or emotionally, all while dealing with cancer.

Months after my mastectomy with DIEP reconstruction, I faced another challenge with prior authorization denial. My surgeon ordered an MRI of my breast, but the prior authorization was denied. How could a well-known insurance company deny an MRI for one with a history of breast cancer? It turns out this happens more often than one realizes, according to several of my physicians. Following a required peer-to-peer discussion between my breast surgeon and the medical director of the authorization department, the MRI was finally approved, a very good thing.

The MRI detected a suspicious area in my reconstructed breast. Biopsies revealed residual breast tissue had developed a more advanced invasive breast cancer. This was shocking for me, and I have learned that it can occur, regardless of the surgeon’s skill. With the change from radical mastectomies to more simple mastectomies, there is an increased chance with an aggressive large tumor, like mine. I share this part of my journey to promote education and awareness, not fear or anxiety for post-mastectomy patients. One should discuss with their physicians what is needed for post-mastectomy surveillance, and that care should be covered.

I firmly believe without my post-mastectomy breast MRI, my unbeknownst more aggressive cancer could have become metastatic, costing more money to treat and impacting my quality of life.

Despite dealing with prior authorizations denials and having to appeal claims, I ultimately had my choice of breast reconstruction and my breast MRI to discover my residual breast cancer. I won my appeal for my DIEP, because my husband and I had medical background, knowledge, and wherewithal to deal with this unbelievable limit of choice. There are many others who don’t have this advantage. No one should have to deal with cumbersome prior authorizations and appeals, while dealing with cancer. Delays may result in poorer outcomes and wastes qualified physician and staff time.

I now advocate for equitable access to cancer care through the American Cancer Society Cancer Action Network (ACS CAN), because of what I went through. In 2021, ACS CAN belonged to a coalition that helped pass HB261, which brought reform to the prior authorization process as it applies to state regulated health insurance plans. Because of this policy, healthcare plans and utilization review agents are now required to accept a uniform prior authorization request form submitted from all providers.

That’s only a start.

While prior authorization can be a useful tool for the health care system to save resources, it cannot be allowed to be used as an obstacle to receiving valid medical care recommended by a physician in good standing. The prior authorization process should be simple for patient care. Dealing with a cancer diagnosis is enough. Our time should be spent on recovery and treatment, not countless hours of paperwork, phone calls, and denials for appropriate procedures and care during treatment and survivorship.

I’m fighting for others because no one should experience what I went through when dealing with prior authorization denials and our health care system. There are some resources that hopefully help with the challenges.