Monday morning. The clinic was crowded, and my in-basket was full. I scanned it quickly for urgent messages. One refill request was flagged with a red exclamation point. The name was unfamiliar, and I checked the chart. Ms. Woods, a woman in her sixties, had developed uncontrollable oral movements, a rare side effect of a medication she was taking for nausea. She saw a colleague who stopped the drug and prescribed a recently approved medication for her involuntary movements. When Ms. Woods saw him in follow-up, shortly before his departure, her movements were less severe and she was able to eat without biting her tongue and cheeks.
I was familiar with her medication, one of many expensive new drugs developed for rare conditions. All of them require prior authorization for insurance coverage. Once approved, refills are generally routine. But a month earlier, Ms. Woods’ husband had called when her last refill did not arrive. Without the medication, the movements had recurred, and Ms. Woods fell, injuring her leg. She went to the emergency department, and her leg was placed in a brace. In the most recent message, her husband reported that she was back on her medication—he had obtained an emergency authorization for her refill. Now the prescription was due for renewal.
Before starting clinic, I wrote the new prescription and completed the required prior authorization form. In a few days, another urgent message appeared. Authorization denied. This was not uncommon—each year, insurance coverage had to be renegotiated. An initial denial was standard, intended to prompt a switch to a less expensive drug. I appealed the denial, sending off my usual letter of medical necessity—failed previous therapy, stable on chronic treatment, FDA approved for her condition. The reply arrived 10 days later. Appeal denied.
I learned from the clinic pharmacist that her insurance company now required a physical examination and a checklist rating the severity of her symptoms. Ms. Woods had been on this medication for almost a year. There was no question that it had improved her symptoms. Soon she would be out of medication again. I submitted a request for a “peer-to-peer” call, to speak directly with the medical reviewer. Another week passed. On Friday afternoon, I saw the next message. Request denied. The insurance company required a second appeal—with the checklist.
I called to let Ms. Woods know what had happened and to set up an appointment for the examination and checklist. Mr. Woods answered, and I introduced myself. He told me Ms. Woods would run out of her medicine on Sunday. I offered to see her on Monday to complete the checklist. They lived 3 hours away, and Ms. Woods was now using a wheelchair. Her husband would need help to bring her. He was worried about COVID-19. And she was scheduled to see an orthopedist later that week.
“Let me see if there’s anything else I can do,” I said.
Call by call, I worked my way from the specialty pharmacy to the insurance company and back. After a few minutes on hold, I spoke to Joanne in the specialty pharmacy. She listened to the story and connected me to Crystal in the pharmacy’s preauthorization department.
“I wish I could help, but we can’t provide even 1-month supply without the prior authorization.”
I moved on to Ms. Woods’s health insurance. I waited for instructions as the prerecorded message played: “If you are a former member of the armed forces or federal employee, we thank you for your service. Please listen carefully to the following options as our menu has recently changed…” I listened carefully, but the option I selected sent me back to the specialty pharmacy. I tried a different option and reached Debby at the insurance company.
I asked if she could connect me with the medical reviewer. After a few minutes, she was back on the line.
“I’m sorry,” she said, “but for this medication, you will need to file a second appeal. I’ll connect you to the specialty pharmacy. They may be able to issue an override.”
When Maxine at the specialty pharmacy came on the line, she introduced herself with the now familiar script. “How can I help you?”
“I suspect you can’t,” I answered,” but if you can, I am prepared to send you a dozen roses.”
That got a laugh and a call to her supervisor, but neither could cut through the Gordian knot of red tape. Nothing could be done until the second appeal was submitted—through e-mail, with the checklist.
I thanked her and called Mr. Woods.
“Alright, Doc. I’ll see if I can get my son to drive us. We’ll be there on Monday.”
I was glad he’d have help.
When I checked the forecast Sunday night, flash flood warnings stretched across the map. I slept fitfully, listening to the rain. In my mind, I saw the dense fog that often obscured the last mountain between the town where Ms. Woods lived and our hospital. But on Monday afternoon, there they were.
With a wave to their son, Mr. and Ms. Woods followed me from the waiting room. Mr. Woods was a small man with a wiry build. He handed me a folder filled with papers and took the handles of Ms. Woods’ wheelchair as we headed down the hall. Once in the examination room, I glanced at the paperwork and asked Ms. Woods some initial questions. Her blue dress was meticulously pressed, and her shoes polished. Her voice was clear and relaxed as she answered, despite the almost constant movements of her tongue and lips.
Mr. Woods continued, outlining his wife’s illness and treatment, rarely consulting his notes. As he talked, Ms. Woods listened closely, sometimes correcting his account or supplying additional details. She smiled easily, occasionally nodding or shaking her head in an unspoken commentary. As he finished, Mr. Woods added, “She doesn’t complain much, but when the movements get bad, she gets pretty anxious.”
During the neurologic examination, Ms. Woods rocked from side to side in the wheelchair, occasionally twisting her neck or lifting her arms abruptly. I completed the checklist. When I’d finished, I gave her a short-term prescription for another medication to calm both her and her movements.
They both thanked me, more than once.
“I wish we could have gotten this done without having you come in,” I said.
“That’s OK,” Ms. Woods answered with another smile. “I’ve been waiting for my son to take me for a ride in that new car of his. He made me promise we’d be back in time for supper.” They both laughed.
“I’ll let you know as soon as we hear from the pharmacy,” I added. “Now that we have the checklist, I hope it won’t take long.”
“My birthday’s coming up, “Ms. Woods said. “Maybe I’ll get it in time for my birthday.”
Another round of “thank you’s” followed. I added mine—for their patience.
Two days later, the prescription was approved. Ms. Woods received a letter with the approval and a call promising delivery. I was relieved that the problem had been resolved.
But a week later, I saw another message from Mr. Woods. Puzzled, I picked up the phone.
“Mr. Woods? It’s Dr. Harrison.”
“Hi Doc. I knew it was you as soon as I heard your voice. You’re just about family by now,” Mr. Woods answered.
“She never got the medicine?” I asked. Despite the approval letter and the call, the prescription had not arrived. Mr. Woods had called the specialty pharmacy and was told they needed the prior authorization number. By now, Ms. Woods had been out of medication for over a week.
“How is she doing?” I asked.
“She’s doing OK,” he replied. “She saw the orthopedist last week and he put a cast on her leg.”
I called the specialty pharmacy. Per the computer, the prescription had been authorized but the new start date had not been entered. The representative assured me that the medication would be sent overnight. He promised to call Mr. Woods.
I called Mr. Woods with the update and asked him to let me know when the medication arrived. He thanked me again—more than once. After I said goodbye, he stopped me.
“Tomorrow’s her birthday,” he said.
Ms. Woods received her medication—not on her birthday, but the day after—reason enough to celebrate a second time.
It had been 6 weeks since the first message. In less than a year, the process would begin again.
- Received June 7, 2023.
- Accepted in final form July 6, 2023.
- © 2023 American Academy of Neurology