Case 1 denied: Calcitriol is a vitamin

One of the more frustrating aspects of medical practice is fighting with insurance companies to get our patients the care they need. As preventionists, endocrinologists struggle to keep our patients out of the hospital while also trying to minimize health care costs. We spend hours every day completing prior authorization forms, sending letters of appeal to insurance companies and explaining why our patients deserve the care we recommend.

At the same time, we see wasteful over-utilization of resources, unnecessary procedures or imaging studies, and hospitalizations that could possibly have been avoided. And yet, no one questions any of that.

The following three posts are a series of cases that I have seen. I am sure all of you have had your share of similar cases.

Patient 1 is a young man in his early 20s who had hypocalcemia due to hypoparathyroidism that was well controlled with oral calcium and calcitriol. However, his insurance changed. No longer would his prescription of calcitriol be covered under his prescription plan.

The reason? His prescription plan did not cover vitamins or nutritional supplements.

Finances were limited; he tried to make his calcitriol last by skipping doses and increasing his oral calcium to 5,000 mg a day. Unfortunately, he ended up having to go to the ED with severe cramps and tetany due to severe hypocalcemia.

It was then he came to see me as a patient. I sent a letter to his insurance explaining how calcitriol, although it is indeed the “active” form of vitamin D, is only available by prescription. Therefore, I explained that it should be covered considering that it is a prescription medication being used to treat a medical condition. Calcitriol is not analogous to nutritional supplements or over-the-counter vitamins used for health and wellness. I requested that the calcitriol be covered.

I received a curt reply, advising me in no uncertain terms that vitamins were not covered by his insurance plan. Calcitriol is a vitamin and, therefore, our appeal was denied.

Two weeks later, the patient then suffered another episode of severe hypocalcemia. He had to go to the ED for tetany and treatment with IV calcium.

Next, I called and spoke with a medical director. The physician was an older family physician who seemed pleasant enough. Although he understood my concerns, he told me that his hands were tied. If he made an exception to cover a vitamin for this patient, then they would have to cover all vitamins for everyone. The second request for calcitriol was not be approved.

After two more ED visits for treatment of severe hypocalcemia, we finally received notice that the case was re-reviewed. It was decided that in the future, his prescription of calcitriol would be covered.

Can you imagine how many prescriptions of calcitriol could have been paid for if even only one of these ED visits had been avoided, not to mention all four of them?

– To be continued –