I’d like to encourage anyone trying to get insurance coverage for Radicava not to give up. My wife is further along than many of you in her ALS progression and she was just recently approved for coverage. It remains to be seen if she will go ahead with getting the infusions, as it will be a significant challenge for her to do so. It is also hard to argue that she will see enough benefit to warrant all the effort, additional discomfort and potential side effects. Still, she figures she has nothing to lose and was very pleased to at least have the option to go forward.
Her insurance company initially denied coverage and then denied our appeal. Her appeal was then sent by the insurance company to an independent reviewer. They subsequently approved coverage. An insurance company representative called and said they were approving my wife for an initial three month period.
Here is a key paragraph in the independent Reviewer’s approval letter:
“Our Doctor Consultant looked at the file for this case. This doctor says that the medication is medically necessary. Our doctor found that the submitted records show the enrollee has a diagnosis of ALS. The FDA has approved Radicava for use in ALS. The FDA did not place any limitations on use of the drug. The FDA has given blanket approval for this drug and as such, the enrollee has a diagnosis for which the drug is approved for use and it would meet Medicare criteria for coverage.”
All the best…Jonico
