A Chicago-area mom who is battling an aggressive form of breast cancer said coverage for her preferred chemotherapy treatment was being denied by her insurance company.
After NBC 5 Responds started asking questions however, the insurance company reversed course and approved the medication.
Crystal Gorski, 37, was diagnosed with triple negative breast cancer in June and underwent a lumpectomy soon after, and then began a series of chemotherapy treatments.
“With this type of cancer, it’s very aggressive,” Gorski said. “It likes to move around. If it does come back, it comes back as a stage four.”
Gorski credits a strong family support system with helping her in the treatment process.
Though during her second round of chemotherapy, Gorski said her body reacted negatively to the steroids used in the treatment process. She said she experienced a racing heart and spent three nights in the hospital. For her third round of chemotherapy, Gorski said doctors lowered the amount of steroids. While her heart rate was not impacted, she said the treatment made her feel weak.
Gorski said she and her doctor then agreed to pursue another chemotherapy drug called Abraxane.
“The Abraxane would be a lot less abrasive on my system and I wouldn’t need those steroids in order to have that treatment that would do the same thing as the other two treatments would do,” Gorski said.
However, Gorski informed NBC 5 Responds via text message that she received a phone call from an Ambetter representative telling her that her medications had been approved without any additional questions.
“It made me cry my eyes out the day before Thanksgiving when I found out,” Gorski said.
She voiced her concerns on Ambetter’s Facebook page and was later contacted by a company representative, who told her it would take 15 business days to receive an answer.
Caitlin Donovan of the Patient Advocate Foundation said patients have the right to request an expedited appeal, which is typically answered within 24 hours. She advised patients experiencing similar insurance denials to stay organized, document everything and confirm the correct insurance is on file.
“Because there could be a very simple fix to your problem that doesn’t involve escalating to a long, drawn-out appeals process,” Donovan said.
Donovan said a patient’s best ally is their doctor.
“They’re the ones who are going to be able to write what’s called a 'letter of medical necessity,' that’s going to outline to the insurance company, why you need the treatment,” Donovan said.
Ambetter and its parent company did not respond to NBC 5 Responds’ request for comment.
However, Gorski informed NBC 5 Responds via text message that she received a phone call from an Ambetter representative telling her that her medications were been approved without any additional questions.
“Yay! I can’t explain in text how happy I am!!” Gorski said via text.
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