We had an interesting dilemma in the office. You see, being pulmonologists we treat people with asthma, and one of the more useful drugs we have in the ammunition belt is a medication called omalizumab (Xolair).
Among patients in whom it’s indicated, particularly those with severe allergic asthma, the effects can be dramatic and life altering. The problem with this drug is the cost. Actually also the administration. And the anaphylaxis. Not to mention all the documentation required to prescribe it. Oh and also the frequency.
The biggest problem with prescribing the drug is its huge cost, which can be somewhere north of 1,000 bucks per month not including the cost of giving the injection. For this reason insurance companies are naturally hesitant to cover it without making sure the ordering physician has all their ducks in a row (i.e. jump through hoops, bend over backwards). One of the more important parts in doing this has been documenting the presence of allergies.
And here’s where it got tricky. In the past, documentation of allergies required a referral to an allergist who performed those prick tests we all remembered when we were kids. However in the past few years the RAST (radioallergosorbent test) has become increasingly available at most labs, which allows us to document allergies and bypass the pricks (no pun intended). But here’s the problem with the RAST; it’s also very expensive (is there anything cheap in medicine anymore?) As a result, medicare seems to have put up barriers to it’s use, restricting coverage for the test to very specific diagnoses.
So when we had a patient in which we thought prescribing omalizumab might be useful, we ordered a RAST, and the fun began. You see, the lab will not do the test unless the insurance (in this care, medicare) defintely covers it, otherwise, they have to send a bill to the patient who may not pay them back. Therefore, before drawing blood, the lab worker inputs the type of insurance and then the test into their system with the diagnosis code that we have specified, in this case, allergic asthma. The computer, who in it’s infinite wisdom knows which diagnosis will be accepted by the patient’s insurance, either accepts the code or it does not.
It did not.
The lab tech calls back to our office and says that we need a different diagnosis or the test will not be covered, and hence will not be run. The computer will not tell us which code to use, it will only tell us if the diagnosis is accepted or not. No sweat, the patient has a slew of diagnoses, we say. Try one of these: chronic asthma? No. Obstructive asthma? No. Allergic rhinitis? No. We try others, going through many of the patient’s varied diagnoses. Each time we are shot down, the computer seemingly having slipped into crazy Soup Nazi mode: “No test for you!”
We speak with the manager, “what diagnosis should we use”? We could look through the patient’s chart to see if the patient would qualify. Sorry, not allowed to tell you, she says. And that is where we have left it, our quest for the magic password has been thwarted … for now.
Deep Ramachandran is a pulmonary and critical care physician who blogs at CaduceusBlog.
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