Let me begin this case study health tip with some related background. Girding their corporate loins for the arrival of the Affordable Care Act (ACA), the health insurance industry has taken some predictable steps to prepare for 35 million new enrollees, many of whom, having had no health care most of their lives, are probably not in the pink. One of the most disturbing of these industry maneuvers is to stop paying for tests, medications, and surgical procedures that were once routinely covered. The most common reason for denial is “unproven” or “experimental,” even for tests and therapies that have been around for decades.
The Food and Drug Administration (FDA) and the health insurance industry are far more intimate than most people realize. Each time the FDA approves a test or medication, your health insurance should cover it (though your insurer is still able to deny coverage). So it’s in the best financial interests of health insurers to keep tests unapproved and, in the case of medications, to push for them to be made available over the counter, where you can pick up the full tab. Medications, surgical appliances, and lab tests can take years to get FDA approval, and during this period the insurance industry can deny payment if your doctor orders them.
“Why aren’t these meds/tests approved?” you might reasonably ask. Because many are in the public domain and can’t be owned by a single company, thus blocking potential mega profits. Thus no company is inclined to pay the enormous sums required for the extensive application and testing process needed to garner FDA approval.
For example, this year women across the country who use bioidentical hormone therapy from compounding pharmacies discovered to their dismay that their insurers no longer covered it. Frantic calls to various pharmacies and insurance companies produced the non-answer “something to do with the FDA” or simply “we don’t know why.” The fact is that compounded hormones cost insurance companies too much money ($75 to $100 a month on average per patient) when compared to generic tablets of concentrated pregnant mare urine (Premarin and Prempro, imported from India @ $5 to $10 per 100 tablets).
Another example: after decades of reimbursing for food sensitivity testing, as of the first of this year Blue Cross and other insurers all decided that since the test had never undergone the FDA approval process, they could wiggle out of paying for it. The test itself, checking for sensitivities to 96 commonly eaten foods, costs about $350, but since a lot of doctors do use it the insurance industry spotted a quick way to save some money.
Food sensitivity case histories
As regular readers know, I’ve been mightily impressed by this test, especially for patients suffering a variety of chronic symptoms that have eluded the usual parade of conventional specialists. Let me share a few of these interesting cases, with names changed to ensure privacy. What’s truly shocking is that this simple test (a blood draw) could save insurers untold millions wasted in specialist visits, invasive diagnostic tests, and surgical procedures.
More eczema than child One of my first patients with sensitivities was a five year-old-girl who scratched herself constantly and had to wear thick gloves to prevent her fingernails from opening up her blistering lesions. Her mother was frantic, carrying a bagful of creams and ointments from one dermatologist to the next. She’d resisted their suggestions that her daughter take oral steroids and immunosuppressive medications to quell the eczema. The child’s food sensitivity blood tests came back with very strong reactions to dairy. After total elimination of all dairy (both straight, like a glass of milk, and in cooking), her skin cleared completely in less than a month.
Heartburn hotel Rachel, a lovely woman in her mid-20s, spent years in and out of gastroenterologists’ offices for her heartburn, also called gastroesophageal reflux disease, or GERD. She’d undergone repeated gastroscopies (I couldn’t imagine why she’d need more than one, but remember medical profits are procedure-driven), which confirmed esophageal irritation. Rachel’s symptoms did respond to proton pump inhibitors (PPIs) like Nexium, but she developed an unusual side effect to them–high blood pressure. Sensibly less than thrilled at the prospect of taking PPIs for the rest of her life, Rachel came to us and when we tested her she showed high reactions to both dairy and wheat. With complete elimination of both, one week later she told me she knew she was getting better. Within a month, Rachel was symptom-free and off PPIs permanently, her blood pressure falling into a comfortably normal range.
Chronically ill Recently the 50ish Rob was referred to me for what could best be described as years-long poor health. His symptoms included chronic fatigue, brain fog, and joint and muscle pain. With a briefcase full of negative test results, he might have been diagnosed with fibromyalgia had not his food sensitivity profile demonstrated major reactions to gluten. Within a month of eating gluten-free, he was astonished by his return to robust health.
That’s not amore Diane inadvertently revealed her diagnosis during her first visit. She’d made an appointment to discuss her chronic sinus congestion (and she did sound extremely congested when she spoke). Diane had already undergone two sinus surgeries, which provided temporary relief, but now she was back to square one. When I asked if she’d ever felt completely fine, she said “Definitely! When I was stationed in southeast Asia during my Peace Corps years.”
“And when did your symptoms return?” I asked.
“Literally on the way home. I spent a couple weeks in Italy and by time I got on the plane back to the US my sinuses were rock solid.”
Diane’s food sensitivity testing showed markedly positive reactions to gluten. When she lived in Southeast Asia, a rice-based culture, she’d eaten virtually no gluten-containing foods. But once in Italy, aching for huge plates of spaghetti Bolognese, Diane had fulfilled her craving with wheat-based pastas and all her symptoms returned.
One final and very ironic note on all this. If you actually call Blue Cross and say “My doctor would like to order food sensitivity testing. Is this covered by my policy?” chances are good a very pleasant customer service rep (and they’re really all quite nice on the phone) will tell you that, yes, it’s a “covered benefit.” Then, when you (or we) submit your claim, it’s denied.
“What?!” you sensibly scream.
You call them back, smoke pouring from your ears. This time, another rep will tell you “Oh, dear! I guess you haven’t read your policy. Having a covered benefit isn’t a guarantee of payment to your provider. We review these on a case-by-case basis and in your case, your covered benefit has been denied. We can fax you the Appeal Process (about six pages long), which includes the address of the Illinois Department of Insurance if you wish to register a complaint.”
The take-home message? If you sense that food sensitivity testing might be a next step in resolving your chronic symptoms, pay out-of-pocket for this valuable diagnostic test or try the DIY version.
Be well,
David Edelberg, MD