PERRYHALL, Maryland – The family is warning other patients to fight for health insurance coverage after their daughter's medication was initially denied by a benefits plan. Despite considering medically necessary treatment, the pharmacy benefits manager refused compensation based on the patient's age.
The drug Rinvoq is approved for use in young children as young as 2 years old, but in the condition of Milana Scaccio, the medical label indicates that it is intended for patients over the age of 18. Scaccio is 17 years old and without insurance, the required dose of medication costs around $13,000 a month.
“January 29th was when I first entered the hospital,” recalls Milana.
Shortly thereafter, she was diagnosed with severe ulcerative colitis and required a blood transfusion during her stay in multiple hospitals to deal with anemia.
“By the time she was recognized, her hemoglobin was five years old. So it's when I really started to worry. How much can this continue before it's life-threatening?” said Milana's father, Elio Scassio.
Her doctors have tried a variety of treatments, including heavy steroids and infliximab injections, but her condition did not improve.
“That didn't work either, so there was nothing else approved. There was nothing else to help her until the doctor tried out Linvok,” explained Milana's mother, Gina Piscopo.
Almost immediately, Milana and her family noticed a positive change.
“I'm not dizzy anymore, I just feel better,” Milana shared.
Her mother said, “On the first day she walked to the elevator, and then she could walk downstairs completely without a wheelchair.”
However, as her health improved, the family learned that Medimpact, the insurance company's pharmacy benefits manager, refused to cover Rinvoq.
“She was 17 and a half years old and technically approved for the age of 18 because of her clone status and colitis. So, due to that six-month gap, she is in this gray area. However, Limbok is available to adolescents if she has eczema,” explained Elio.
After initial denial, the family appealed the decision on Medimpact, but faced another set-off. Milana doctors then drafted a letter justifying the need for medication and filed a complaint with the Maryland Department of Health (MIA).
Meanwhile, Milana stayed in the hospital.
“I finally feel much better than before [and] All the other time in the hospital, and I just had to sit there, and I couldn't go home, meet my friends and go to school at all,” Milana said.
“She couldn't leave. If she left, she would soon be back if she didn't continue taking the medication,” her mother added.
Eventually, the families learned that their appeal would be sent to an independent review organisation, marking the final stages of the appeal process. And recently they got the news they wanted.
“It was overturned by that third-party reviewer. We are grateful,” Elio said.
According to the MIA closure letter, “The Independent Review Agency (IRO) physician reviewer and accredited board of directors in the pediatric gastroenterology department have determined that it is a medical drug for patients.”
In 2023, 69.7% of carrier complaints handling decisions courtesy of consumers were reversed or changed in accordance with MIA data, but it could be a long and boring appeal process that many patients don't know about.
Now, Milana and her family can be relieved and they can focus on her healing and graduating from high school.
“You can just go back to school and hang out with friends like you used to,” Milana said.
WMAR-2 News Mallory Sofastaii I emailed Medimpact to request information about rejection, but there was no response.
If you are denied by your health insurance company, you can first file an internal appeal. If it is rejected, you can request a second, more detailed appeal. Depending on your health insurance plan, submit an external appeal to the MIA, or Self-funded insurance plans You can request independent reviews from outside parties through your employer. Your doctor may also be able to assist in filing an appeal.
To file a complaint, or to details about the Maryland Department of Insurance, click here.
The Maryland Attorney General Health Education Advocacy Unit (HEU) also supports medical claims disputes in Maryland. click here For more information.
