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High-Dose Chemotherapy: Ensuring Coverage for Your Client

by Arthur M. Gorov
Reprinted with permission from the Professional Negligence Law Reporter, copyright of the Association of Trial Lawyers of America.

More and more, oncologists throughout the country are prescribing, as the best, and often last chance, treatment for women with recurrent ovarian and breast cancer, a regimen involving high dose chemotherapy supported by either a bone marrow transplant or a peripheral stem cell rescue.

High dose chemotherapy involves the administration of extremely high, potentially toxic, doses of chemotherapy in an effort to eradicate cancer cells. Unfortunately, the chemotherapy also kills healthy bone marrow, which produces white blood cells to protect the body from infection. Thus, if high dose chemotherapy is administered without some additional support to regenerate bone marrow, the patient has little, if any, chance of surviving the treatment. High dose chemotherapy can be given without the bone marrow regeneration, but it involves an extremely lengthy stay in the hospital, at least three months, so as to protect against infection, and the ultimate results have been much less satisfactory with regard to the success of the treatment.

Autologous bone marrow transplant ("ABMT") and peripheral stem cell rescue ("PSCR") are two methods used to regenerate bone marrow. With ABMT, prior to the administration of high dose chemotherapy, healthy bone marrow is removed from the patient, who is placed under general anesthesia while bone marrow is extracted by needle. Stem cells are removed from the marrow and frozen. The stem cells are then reintroduced into the body, intravenously, following the chemotherapy, for the purpose of causing the patient's bone marrow to regenerate.

The same result can be achieved through PSCR which involves a process similar to collecting blood. With PSCR the stem cells are harvested from the patient's blood, which is removed by placing a catheter in the patient's chest. This process does not require general anesthesia. As with ABMT, the stem cells are reintroduced intravenously following chemotherapy.

Unfortunately, apparently due to the high costs of the treatment, many health care coverage providers, insurance carriers, HMOs, etc., are refusing coverage for the treatment on the basis of several provisions of their policies/plans. Most often encountered are the allegations that the treatment is experimental in nature or is not included, or is specifically excluded, by the terms of the policy, in one way or another.

In most instances, by the time that the women consult with you, seeking your advice on how best to proceed, time is of extreme essence. They have, usually, with the assistance of their physicians, already tried, unsuccessfully, to convince the health care coverage provider that preauthorization and coverage for the treatment should be granted. You will often find that the physicians will give you only a small "window of opportunity" before the treatment must begin, if it is to have any reasonable chance of success.

This article is designed to discuss the best and quickest way we have found in which you can assist your client in obtaining the coverage needed so that she can obtain the prescribed treatment.