Insurance 3rd Party Arbitration of Danazol

I've been trying to get BCBS insurance company prior approval for Danazol treatment.

The initial rejection was that it didn't meet their Anabolic Steroid Guideline . From reading the guideline, I suppose the reason is that Danazol would be an 'off label use'. But what drugs are 'on label use' for treatment of ITP? The only ones that come to mind are Promacta and NPlate. AFAIK, all other drugs, like Prednisone, IVIG, Rituxan, WinRho, are off label. So that reasoning is flawed/insufficient.

I appealed the decision for 'third party arbitration' and received the results of arbitration a few days ago. Was a bit surprised when I received it because I was never given the opportunity to submit evidence prior to the decision. Where was the arbitration? The decision is to 'agree' with the insurance company. Basically it says
'The use of Danazol in treatment of patients wit ITP is not supported by the most current practice guidelines, peer-reviewed medical literature, and specialty physician recommendations'.
At the end, it makes reference to these three studies - all I had seen before.

ITP: a practice guideline developed by explicit methods for the American Society of Hematology

Danazol therapy in patients with chronic ITP: long-term results

ITP: a retrospective analysis in 139 patients of the influence of age on the response to corticosteroids, splenectomy and danazol

I've re-read all three studies. None of them support the statement made by the arbitration board. It is just the opposite. The use for ITP is absolutely supported. The studies go into detail about when, and on who, it is best used. To me the arbitration was phony. As a trivial and obvious example of its efficacy, Danazol is listed as a treatment for ITP on the PDSA website. Duh.


It is obvious to me I have a small claims case. Or, am I not thinking this through well enough?

Insurance companies keep denying claims simply because they can. There shouldn't be any real reason for your denial. I had no trouble having it approved way back when I tried it. I never even finished the bottle though because I broke out in hives.

A small claims case where? It might end up costing you more to file a claim than it would be to just pay for the drug for a few months and see what it does. I know these studies tout success, but I have not really seen that here. The people who have tried it usually don't stay on it very long. It either doesn't work well or they have side effects. In the short time I was on it, I got a huge boil on my chin....one of the side effects. It says 'acne' but it's a bit worse than that.

Hal that's crazy. I also live in Texas and have BCBS. Although I never started Danazol my doctor got it approved twice, he also has been able to get IVIG and Rituxin approved in just a day or so. His office is in The Center for Cancer and Blood Disorders in Fort Worth. I don't know what the difference is but they do have a staff that does all approvals.

Sandi, yes there is no real reason - especially since Danazol is one tenth the cost of Promacta. If you've still got that bottle, I wonder what the shelf life is, LOL.

I've watched too much 'People's Court'. I think it would be fun to present a case in small claims court. Need to research the particulars - how to sue in whichever Texas county BCBS is registered in. The filing fee is like $35. I'll have to incur the drug cost then sue to get the money back. Because insurance policies and laws are a big question mark next year, I think I'll table the Danazol issue until the end of year. Get the insurance company to pay for Promacta this year.

D.Mann, didn't you mention that your drug coverage is with a different company than BCBS?

When the world seems to be against you, one has to revert back to the most reassuring phrase ' there is no place like home ' !

BCBS for hospital and IV type stuff, but Medco for monthly prescriptions.

Good luck with that, Hal.

Have you ever read the Rainmaker by John Grisham?

Oh ok D.Mann. I was thinking Medco was prescription drug insurance, and not a pharmacy.
Yes, this is crazy. Makes no sense to me. Then the adverse arbitration decision was over-the-top nonsense. I don't pay monthly insurance premiums only to end up paying for drug treatments. Often when they interview plaintiffs at the end of the show on People's Court, they say they sued because of 'principle'. A defendant trying to get away with something. And this is the reason I will be going to court too. It's the principle of the matter.

Oh, and then there is the notion of ' treble damages ' when one can show 'willful' damage by the defendant. That is where one can get three times actual damages to teach a lesson. Not sure if treble damages are allowed in Texas.

Sandy, I haven't read that. But I did look up the story on Wikipedia, LOL. Lots of unintended consequences when suing, or ?

Medco is the prescription insurance.

Hal - I'm not a lawyer but I am (was) a paralegal with a degree. Usually when you sue, you have to claim monetary damage...damage to person, property, income, etc. In other words, there has to be a monetary loss or some type of harm done. Taking on a huge insurance company for drug denial might entail much more than small claims court, especially when you don't really have a claim for damages. Since they are not denying all treatment and it's not a life-threatening situation, I'm not sure what the claim of harm/damage or loss would be. Judge Wapner and People's Court is TV drama. If people could really sue for 'principle', I can't even imagine what the court schedules would look like!

Sandi, I remember watching People's Court with my Dad on holidays. We would argue and try to guess Wapner's decision before he made it. To me, this case is straight forward - a no brain'er.

First Danazol is on BCBS published formulary list, so that is not a problem. They must pay for the drug when it is prescribed - perhaps not all but at least for some patient conditions. That is what they agreed to do when I purchased their insurance and gave them money for their promise.

Next, BCBS has created and publicly published a document governing Danazol usage that they say they are going to use - Anabolic Steroid Guidline . So the only thing I must do to collect monetary damages is to show they aren't following that document.

As the arbitration result letter showed, they don't have any published studies showing Danazol is ineffective in treatment of ITP. All they could furnish were studies that did in fact show Danazol is effective.

I'm not arguing that you shouldn't have it. I agree with you. Your logic is valid, theirs is not. You're right. The only thing they might catch you on is if they list certain illnesses that they allow Danazol to be used for and ITP may not be on that list. I don't know. It does seem silly to deny that drug when the cost is low in comparison to some of the other ITP treatments that you would be forced to use instead. Their logic is really skewed. They'd save $190 a month but end up spending $1,000 (or more) a month.

All I'm saying is that from a legal standpoint, you'd have to prove harm/damages resulting from the drug denial to have a case. Maybe Emily or Norma can weigh in here. I'm just not seeing it, maybe they can. If you do decide to sue then by all means, go for it. I'm interested to see how it would go. Also keep in mind though that small claims court gives small rewards.