After being denied reimbursement for Rituxan treatment that complimented her chemotherapy, 20-year-old Jennifer McDonald welcomed a recent ruling from the State Department of Insurance finding that her insurance company, United Healthcare, must pay for the Rituxan treatment that successfully eradicated her cancer. The decision is likely to impact the treatment for other individuals living with Hodgkin's disease - about 8,000 Americans are diagnosed each year with Hodgkin's, and some 400 of them are McDonald's subtype.
Second-year law students Charles Dunham IV and Laura Kenney, working in collaboration with McDonald's physician, Jennifer Pearce, an associate professor at Albany Medical Center, filed an external appeal of the denial to the State, submitting medical journals showing Rituxan's effectiveness in treating the type of Hodgkin's lymphoma which McDonald was fighting.
"This decision not only relieves Ms. McDonald's anxiety about trying to find a way to pay for the Rituxan out of her own pocket - about $40,000 -- but hopefully will lead to a policy change at United Healthcare," said Kenney, "opening the door to other Hodgkin's Lymphoma patients around the country."
"Physicians who are specialists in certain diseases often think creatively and expand the use of beneficial drugs beyond the guidelines of ‘FDA approved' diseases," said Pearce. "We spend a lot of time fighting battles with insurance companies who often stick to rigid guidelines about treatment options. As seen in this case, this leads to a waste of a physician's time and a great emotional and economic burden on the patient that is unnecessary. The Law Clinic is providing a valuable service to the oncology community by helping us in this battle."
In October 2006, United Healthcare denied insurance coverage for the Rituxan treatment Jennifer had received from August 2005 through December 2005 as a compliment to her chemotherapy treatment. Based on its guidelines, United Healthcare found that the treatment was not shown by peer reviewed medical literature to be safe and effective for treating Hodgkin's disease. McDonald was faced with the overwhelming prospect of paying for the costly treatment herself.
In November 2006, McDonald brought her dispute to the Health Law Clinic at Albany Law School's Clinic and Justice Center. Structured on the premise that medical-legal collaboration not only helps resolve legal disputes but leads to improved health outcomes for its clients, the Health Law Clinic offers free legal services to the community while teaching students to be client-centered advocates.
The State found that Rituxan should be covered for Ms. McDonald's Hodgkins Disease because the treatment was likely to be more beneficial than any other existing standard health service. The ruling acknowledged that Rituxan is not approved by the FDA to treat Hodgkin's lymphoma. However, it reasoned that since the FDA had already approved Rituxan for similar non-Hodgkin's lymphoma , some scientific studies had shown Rituxan to be an effective compliment to chemotherapy in CD 20+ Hodgkin's patients, and off-label use of drugs was common in medical oncology, that the Rituxan should have been covered by United Healthcare.