Sheldon Ekirch is used to being disappointed by her health insurance company.<\/p>\n
That\u2019s why Ekirch, 31, of Henrico, Virginia, was stunned when she learned Anthem would finally have to pay for life-changing medical treatment.<\/p>\n
For two years, she had battled the company to cover blood plasma infusions called intravenous immunoglobulin, or IVIG. The treatment has been shown, in some cases, to improve symptoms associated with small-fiber neuropathy, a condition that makes Ekirch\u2019s limbs feel like they\u2019re on fire.<\/p>\n
But Anthem had repeatedly denied coverage for IVIG, which costs about $10,000 per infusion. Then, in February, an external review of her case conducted for the Virginia Bureau of Insurance overturned Anthem\u2019s denial. It meant her parents would no longer need to withdraw money from her father\u2019s retirement savings to pay out-of-pocket. Already, they\u2019d spent about $90,000.<\/p>\n
\u201cMy mom was sobbing. My dad was on his knees, sobbing. I don\u2019t think I\u2019ve ever seen him cry like that,\u201d said Ekirch, describing her parents\u2019 reaction to the reversal.<\/p>\n
\u201cI think I\u2019m in shock from it all,\u201d she said.<\/p>\n
In a prepared statement, Stephanie DuBois, a spokesperson for Anthem Blue Cross and Blue Shield, said IVIG did not \u201calign with our evidence-based standards.\u201d But she said the company respects \u201cthe external reviewer\u2019s decision\u201d to overturn the denial.<\/p>\n
Meanwhile, each year millions of patients like Ekirch continue to face denials through the prior authorization process, which requires many patients or their doctors to seek preapproval from health insurers before proceeding with medical care. And despite promises of reform from insurance companies, denials remain a frustrating hallmark of the American health care system.<\/p>\n
Last June, Trump administration officials announced in a press conference that health insurance leaders had pledged to simplify prior authorization by taking steps such as \u201creducing the scope of claims<\/a>\u201d subject to preapproval. The insurers also promised faster turnaround times and \u201cclear, easy-to-understand explanations\u201d of their decisions.<\/p>\n Yet in February, when KFF Health News contacted more than a dozen major insurers that signed the pledge, half of them failed to provide specifics about health care services for which they no longer require prior authorization.<\/p>\n A January press release<\/a> said the industry remains committed to the effort. But physicians, consumers, and patient advocates are pessimistic about the insurers\u2019 willingness to follow through with these voluntary changes.<\/p>\n \u201cThey have no desire to do what\u2019s in the best interest of the patient if it\u2019s going to hurt their pockets,\u201d said Matt Toresco, CEO of Archo Advocacy, a patient advocacy and consulting company.<\/p>\n \u201cIn the insurance world, the fiduciary responsibility is not to the patient,\u201d he said. \u201cIt\u2019s to the Street,\u201d he said, referring to Wall Street.<\/p>\n Meaningful Change?<\/strong><\/p>\n The Department of Health and Human Services did not respond to questions for this article. The few updates the federal government has issued since June on prior authorization reform include a September announcement<\/a> about ensuring clinicians can submit requests electronically.<\/p>\n AHIP, the health insurer trade group that issued the January press release, did not provide information about specific treatments, codes, medications, or procedures that its members have released from prior authorization since signing the pledge.<\/p>\n \u201cWe will have additional progress updates coming out later this spring,\u201d said Kelly Parsons, a spokesperson for the Blue Cross Blue Shield Association, which represents 33 independent Blue Cross and Blue Shield companies. She also offered no specifics.<\/p>\n Blue Cross and Blue Shield companies that cover patients in Alabama, Arkansas, Iowa, Michigan, Pennsylvania, South Carolina, South Dakota, and Tennessee either did not respond to questions for this article or deferred to the Blue Cross Blue Shield Association.<\/p>\n By contrast, other insurers cited specific examples of change.<\/p>\n Aetna CVS Health began \u201cbundling\u201d prior authorizations for musculoskeletal procedures, as well as for lung, breast, and prostate cancer patients, spokesperson Phil Blando said. This practice allows providers to file one authorization request for a patient\u2019s treatment instead of several.<\/p>\n And Humana removed prior authorization requirements for \u201cdiagnostic services across colonoscopies,\u201d among other changes, spokesperson Mark Taylor said.<\/p>\n UnitedHealthcare, which came under intense scrutiny for its use of prior authorization following the fatal shooting<\/a> of one of its executives in late 2024, removed prior authorization requirements on Jan. 1 for \u201ccertain nuclear imaging, obstetrical ultrasound and echocardiogram procedures,\u201d among other changes, spokesperson Matthew Rodriguez said.<\/p>\n Yet some health care insiders doubt these changes will amount to much.<\/p>\n \u201cInsurers have made similar promises before and failed to deliver meaningful change,\u201d said Bobby Mukkamala, president of the American Medical Association, which represents U.S. physicians and medical students.<\/p>\n In 2018, various health industry groups<\/a>, including AHIP and the Blue Cross Blue Shield Association, announced a partnership \u201cto identify opportunities to improve the prior authorization process.\u201d Yet, Mukkamala wrote<\/a> in response to the June pledge, the process remains \u201ccostly, inefficient, opaque, and too often hazardous for patients.\u201d<\/p>\n \u201cTransparency is essential so everyone can see whether real reforms are happening,\u201d he told KFF Health News.<\/p>\n Curbed Enthusiasm<\/strong><\/p>\n Prior authorization may be getting more political attention, but data shows patients \u2014 particularly those with chronic conditions that require ongoing medical treatment \u2014 continue to face barriers to doctor-recommended care.<\/p>\n Among patients in that group, 39% said prior authorization is \u201cthe single biggest burden\u201d in receiving care, according to a recent poll<\/a> by KFF, a health information nonprofit that includes KFF Health News.<\/p>\n I was fighting to survive, and then I was fighting to convince someone that I deserved to survive.<\/p>\n Anna Hocum<\/p>\n That\u2019s true for Payton Herres, 25, of Dayton, Ohio, who in 2012 received a heart transplant, which requires her to take an antirejection prescription medication for the rest of her life.<\/p>\n But last year, she said, Anthem denied coverage for the expensive drug. She\u2019d been taking it for more than 10 years.<\/p>\n \u201cI\u2019ve been with Anthem my entire life, and then, all of a sudden \u2014 I don\u2019t know what happened \u2014 they just started denying me over and over,\u201d she said. \u201cI almost ran out of medication.\u201d<\/p>\n DuBois, the Anthem spokesperson, confirmed the company has approved the medication. It had not taken Herres\u2019 treatment history into account when it denied coverage for the drug, DuBois said.<\/p>\n But Herres said the company will require her to obtain a new authorization for the medication in September.<\/p>\n \u201cAre they going to deny other things, too?\u201d she asked. \u201cI hope I don\u2019t have to keep fighting like this for the rest of my life.\u201d<\/p>\n Anna Hocum, 25, is preparing for a similar fight. In 2024 and 2025, her insurer repeatedly denied coverage for expensive treatment used to slow the progression of a rare genetic condition that destroys her lung function.<\/p>\n \u201cI just thought I was going to die,\u201d said Hocum, of Milwaukee. \u201cI was fighting to survive, and then I was fighting to convince someone that I deserved to survive.\u201d<\/p>\n Like with Ekirch, Hocum\u2019s parents paid while they waited for her insurance company to overturn the initial denials. Friends and family donated more than $30,000 through a GoFundMe campaign to help defray the costs.<\/p>\n Then last spring, Hocum said, her insurer reversed the denial without an apparent explanation. But the approval is valid for only 12 months, so she will need another prior authorization approval this year.<\/p>\n \u201cIt is scary,\u201d she said. \u201cIt\u2019s not guaranteed that it\u2019ll be accepted.\u201d<\/p>\n They fought me tooth and nail every step of the way, to the point that they made my life a living hell.<\/p>\n Sheldon Ekirch<\/p>\n Even though it\u2019s a \u201chuge relief\u201d that Anthem is now obligated to cover Ekirch\u2019s treatment, her mother doesn\u2019t know if or how the family will recoup the money it has already paid.<\/p>\n In a letter to Ekirch confirming the external reviewer\u2019s decision, Anthem explained that the authorization would be valid for a year beginning on Sept. 25, 2025. \u201cWe are pleased we can provide a favorable response in this case,\u201d a grievance and appeals analyst for Anthem wrote.<\/p>\n Ekirch said the letter highlighted the company\u2019s hypocrisy.<\/p>\n \u201cThey act as though they are a benevolent organization doing me a favor.\u201d In reality, she said, \u201cthey fought me tooth and nail every step of the way, to the point that they made my life a living hell.\u201d<\/p>\n Now, Ekirch\u2019s access to IVIG may be in jeopardy again. Her COBRA coverage through Anthem expires in late March. In April, she will need to transition to a new insurance plan \u2014 and she\u2019s bracing herself for another round of prior authorization.<\/p>\n \u201cI just am so afraid that I don\u2019t have the strength to go through and do what it takes,\u201d Ekirch said, \u201cto fight this battle again.\u201d<\/p>\n Do you have an experience with prior authorization you\u2019d like to share? <\/em>Click here<\/em><\/a> to tell KFF Health News your story.<\/em><\/p>\n KFF Health News<\/a> is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF\u2014an independent source of health policy research, polling, and journalism. Learn more about KFF<\/a>.<\/p>\nUSE OUR CONTENT<\/h3>\n