Why Fighting Back Works

Patient denied Stelara after insurance required trial of methotrexate first. Filed appeal citing liver disease (elevated ALT/AST) as contraindication to methotrexate — a documented clinical exception.

If you have liver problems, methotrexate step therapy can be bypassed.

Patient denied Dupixent because the prescription came from a primary care doctor. Insurance required a dermatologist or allergist to prescribe.

Many plans require a specialist prescriber for biologics. Ask your doctor for a referral.

Patient denied Ocrevus because insurer required trial of older platform therapy (Copaxone) first. Neurologist submitted peer-to-peer review call citing high disease activity and NCCN guidelines supporting first-line high-efficacy therapy.

Peer-to-peer reviews between your doctor and the insurance medical director overturn denials more often than written appeals alone.

Patient denied Keytruda because PD-L1 biomarker results were not included in the original PA submission. Oncologist resubmitted with pathology report showing PD-L1 TPS ≥50%.

Always include biomarker test results (PD-L1, MSI-H, HER2) with your initial PA submission to avoid delays.

Patient mid-chemo had their anti-nausea medication suddenly denied after being on it for over a year. Insurance refused to refill, causing severe nausea during active treatment.

If you're denied a supportive care drug during active chemo, request an expedited/urgent appeal — insurers must respond within 72 hours.

Patient denied Neulasta (white blood cell booster) after chemo. Insurer required trial of cheaper biosimilar Zarxio first, despite oncologist prescribing Neulasta for dosing convenience.

Biosimilars like Zarxio work just as well for most patients. If your doctor agrees, the biosimilar can get you treated faster with fewer insurance fights.

Patient denied Ibrance because insurer required genetic testing results confirming HR+/HER2- status. Testing had been done but results weren't included in the PA submission.

For targeted cancer therapies, always attach your biomarker/genetic testing results to the initial PA request.

“The stress of dealing with insurance was worse than the cancer.”

“I was denied life-saving chemotherapy because my insurance company thought it was too expensive. I had to appeal multiple times.”

“Patients should not have to deal with this on top of the stress of a cancer diagnosis, but if patients don't step in and advocate for themselves their treatment will likely fall through the cracks.”

“If I'm a stage 4 cancer patient with an entire team of doctors saying this is what's best, how can an insurance company who doesn't even know me make a choice for me like that.”