LADUE, Mo. — Over 4 consecutive days in January, Margaret Hvatum ran a 5K, a 10K, a half-marathon, and a full marathon. The 70-year-old lined a mixed distance that’s practically equal to operating the size of Manhattan 4 instances.
By the tip of the month, she was in a hospital mattress.
Hvatum, a part-time pc science professor, has a weakened immune system attributable to a uncommon situation often known as main immunodeficiency, which makes it troublesome for her physique to struggle infections. Previous to her 2005 prognosis, she had 4 bouts of shingles, a painful rash brought on by a virus.
For greater than a decade she relied on an costly medication to deal with her power situation — and relied on her insurance coverage to pay for it.
Then the denial letters got here.
The Medical Service
To offer her weakened immune system a lift, she depends on Hizentra, which is made up of antibodies collected from donated blood plasma.
At her residence, close to St. Louis, Hvatum can administer the advanced medication herself. She makes use of a big syringe to attract the medication from a vial and hundreds the syringe right into a plastic equipment that appears like a toy Nerf gun. She cranks a blue plastic dial that triggers a gentle drip of the medication, and it snakes by way of plastic tubing till it enters her leg by way of a needle.
The Invoice
$8,141.94: The total costs for a 28-day provide of Hizentra with out insurance coverage protection.
After her Medicare Benefit plan by way of Humana denied cost for the drug in January, she missed a number of weekly doses.
The Billing Drawback: Prior Authorization
Hvatum received twisted up within the controversial course of often known as prior authorization, which regularly requires sufferers or their medical crew to get an insurance coverage firm’s approval earlier than acquiring medicines or therapy.
In the beginning of the yr, after Hvatum switched Medicare Benefit plans, she acquired a letter saying that Humana, her new service, had denied her “prior authorization prescription request” for Hizentra. The authorization from her earlier insurer didn’t carry over.
With out the medication, Hvatum developed a urinary tract an infection that despatched her to the emergency room on Jan. 30. Although it’s a widespread an infection, her physician suggested her to go there as a result of folks together with her situation can get sick and deteriorate shortly, she stated.
That ER go to became an in a single day hospital keep. That became hospital costs of greater than $18,000, and once more her insurance coverage denied cost, saying this time that she wasn’t sick sufficient to require hospital care.
Hvatum’s expertise with prior authorization is just not distinctive.
Medicare Benefit plans reviewed practically 53 million prior authorization requests in 2024, in accordance with KFF. That’s equal to just about two opinions for each particular person enrolled in this system.
It’s widespread for Medicare Benefit plans to disclaim cost for care — which helps them make a revenue, stated Carrie Graham, director of the Medicare Coverage Initiative at Georgetown College’s Heart on Well being Insurance coverage Reforms.
The federal government pays a month-to-month sum to Medicare Benefit insurers to cowl take care of every member. “They make a profit if the care that person receives in that year is less than the amount they receive,” Graham stated.
Greater than half of eligible Medicare beneficiaries select Medicare Benefit insurance coverage protection. In 2026, roughly 35 million chosen one in all these non-public insurance policies supplied by insurance coverage corporations.
Humana is a dominant participant within the house. Almost half of all Medicare Benefit enrollees nationwide are lined by UnitedHealth Group or Humana, in accordance with KFF.
The killing of UnitedHealthcare CEO Brian Thompson prompted renewed scrutiny of prior authorization. Final summer time, months after his demise, the nation’s largest insurers, together with Humana, signed a pledge that outlined a handful of commitments to ease the burden on sufferers.
For instance, insurers vowed to scale back the variety of providers that will require prior authorization approval. Additionally they promised to scale back delays by honoring current prior authorizations for a 90-day interval when sufferers switched plans.
That’s not what occurred in Hvatum’s case.
Humana stated this pledge to honor current approvals comes with limitations. “These commitments are for medical services only and do not apply to prescription medications,” spokesperson Mark Taylor stated.
Humana declined to touch upon the specifics of Hvatum’s case, although she agreed to waive her privateness rights, giving the insurer permission to remark.
Whereas acknowledging that the prior authorization course of will be deeply irritating for sufferers, Humana stated it “builds important checks and balances into the healthcare system by verifying that treatments and care delivery are in the best interest of patient safety and quality of care, while safeguarding taxpayer dollars.”
In July 2025, Humana stated it will take away one-third of prior authorization necessities for outpatient providers.
“We are committed to making the process faster and more seamless for patients and providers,” Humana stated in an announcement Taylor offered to KFF Well being Information.
The Decision
Hvatum appealed, and Humana in late January reversed its preliminary cost denial for Hizentra, enabling her to afford her medication once more.
However the approval got here with a catch: It expires on the finish of the yr, after which she would want to acquire approval another time.
Hvatum has since switched to a distinct drug — and he or she may not stick round for any extra medical-bill fights like this one. She and her husband are contemplating a transfer to Norway, a spot with common healthcare. He’s a citizen there, which may give her a path to public well being protection.
The trade’s guarantees to alter are too little, too late for Hvatum.
By her account, she has finished her half. Working is her outlet, perhaps an obsession, and it retains her wholesome. Scores of medals and trophies are tucked about her residence. Some sit on a white wicker finish desk, subsequent to household pictures, candles, and framed St. Louis Cardinals memorabilia. Above a big bay window within the kitchen, medals hold from ribbons of all colours, made to look virtually like customized window material.
“I have done everything I possibly can to be healthy,” Hvatum stated, sitting at her eating room desk in her operating gear. Her printed T-shirt learn, “If found on ground, please drag across the finish line.”
The Takeaway
Knowledge exhibits sufferers ought to attraction prior authorizations, as a result of those that do usually get their denials reversed, Graham stated. The truth is, 81% of Medicare Benefit appeals had been partially or absolutely overturned in 2024, in accordance with KFF.
Comparatively few folks attraction, as a result of “it’s an exhausting process,” Graham stated. It places the onus on sufferers — and docs get annoyed, too.
It’s not simply Medicare Benefit plans that topic enrollees to prior authorization approvals. It’s prevalent in different forms of protection, and it has prompted blowback from the general public. Graham believes the general public outcry instigated the trade’s pledge to alter.
Hvatum is properly versed in submitting appeals. She submitted one other attraction to Humana after the insurer denied cost for her January hospital keep. Humana once more reversed its denial of cost in her case.
Hvatum blames Humana for her January journey to the hospital. Had Humana permitted her Hizentra, she stated, she may have prevented hospital care altogether.
In March, she had a stroke. Humana denied protection of that hospital keep, too.
Humana decided that it was not affordable for the doctor who admitted Hvatum to assume she would want to remain at the least two nights, the brink for approval. “You had a small stroke,” Humana’s denial letter said.
Hvatum famous the letter was dated March 25, two days after she was hospitalized. Humana reversed its denial two weeks after Hvatum appealed.
“They love to send you the denials fast,” Hvatum stated. “Approvals take longer.”
Invoice of the Month is a crowdsourced investigation by KFF Well being Information and The Washington Put up’s Effectively+Being that dissects and explains medical payments. Since 2018, this collection has helped many sufferers and readers get their medical payments lowered, and it has been cited in statehouses, on the U.S. Capitol, and on the White Home. Do you’ve gotten a complicated or outrageous medical invoice you wish to share? Inform us about it!
