Insurance Company Deems Treatment for Baby With Brain Cancer as 'Medically Unnecessary'

Baby in hospital for brain cancer
Wayne Richardson
All sick children should be able to receive the care they need, but unfortunately not all insurance companies see potentially lifesaving treatments as "essential." The cost of medical care shouldn't determine if a kid gets to live or die, but when one dad got a letter in the mail addressed to his 9-month-old son from HIP Health Plan of New York, it came across as if his baby's life wasn't worth what it would cost to be saved to the strangers in the billing department. 

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When Connor Richardson was 7 months old, he was taken to the hospital after his eyes popped out wide and he spent the night inconsolable. "Not like a regular baby, like when somebody dies," his dad, Wayne Richardson, told the Daily Beast

Baby in hospital for brain cancer
Wayne Richardson

Connor was diagnosed with brain cancer and had to undergo emergency surgery to remove the rare tumor that was blocking fluid from flowing to his spine. "The surgeon told me after we left that he almost lost him on the table," Wayne tells CafeMom. "He got 85 percent of it and had to stop due to bleeding." Connor had to undergo an additional surgery the following week in an attempt to remove the rest of the aggressive teratoid rhabdoid tumor.

Unfortunately during a follow-up visit at a different hospital, doctors not only discovered that Connor's tumor had returned, but that it had also spread to his spine. He was quickly enrolled in a clinical trial at St. Jude's Children's Research Hospital, and although doctors and Wayne agree that it's "medically necessary," the insurance company simply didn't agree and opted to try saving money instead of Connor's life.

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According to Wayne, they mailed their decision directly to the infant and explained their reasoning in this upsetting letter:

"As HIP Health Plan of New York, we try hard to provide you with access to quality health care services that meet your needs. When we decide to deny coverage for treatment or service, we want to make sure you know why ....

We look over the clinical and medical information given to us and check the criteria, guidelines and the rules of your health coverage policy to make our decision.

When we reviewed the information given to us about this request, we have decided to deny coverage of the following medical service(s) or item(s) that you or your provider asked for: Inpatient Hospitalization to St. Jude Hospital from 10/4/2017-10/10/2017. We have determined that the service(s) are not medically necessary.

This letter is your Initial Adverse Determination. This means we are denying your quest for coverage of the requested service(s)."

Letter from insurance company
Wayne Richardson

The letter then gave a further explanation for their refusal to cover Connor's treatment:

"Your child is a 9 month old boy who was diagnosed with a high grade brain tumor. Your child was treated with surgical removal of his tumor at Stony Brook Hospital. After your son was discharged you enrolled him in a clinical trial at St. Jude's hospital. The principal investigator has requested medications including methotrexate, cisplatin, cyclophosphamide, vincristine in combination with an investigational medication, alisertib. This combination of medications is not the standard of care for this type of cancer, and is considered experimental and investigational at this time, as evidence-based guidelines do not exist to confirm its effectiveness for his brain tumor. Therefore, this request for clinical trial treatment at St. Jude's hospital is not medically necessary and is denied."

Letter from insurance company
Wayne Richardson

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It concluded by stating that if Wayne decided to move forward with this treatment for his dying son, he would have to pay for it himself. He estimates that it would cost at least $2 million, but luckily for this retired New York Police Department officer, St. Jude offered them the treatment without cost so that Connor could start his chemotherapy journey as soon as possible. "He'll die if you don't do it," Wayne told the Daily Beast

Baby in hospital for brain cancer
Wayne Richardson

As grateful as Wayne is to St. Jude for not letting money stand in the way of his son's medical care, Wayne realizes that the insurance is denying St. Jude funds they need for research by refusing to pay them for Connor's care. Wayne also feels they are withholding coverage his family deserves. "Cancer doesn't discriminate," he tells CafeMom. "I've had the same insurance since '81, have never spent one night in the hospital."

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