Woman Petitions Health Insurer After Company Approves — Then Rejects — Her Infusions
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When KFF Health News published an article in August about the “prior authorization hell” Sally Nix said she went through to secure approval from her insurance company for the expensive monthly infusions she needs, we thought her story had a happy ending.
That’s because, after KFF Health News sent questions to Nix’s insurance company, Blue Cross Blue Shield of Illinois, it retroactively approved $36,000 worth of treatments she thought she owed. Even better, she also learned she would qualify for the infusions moving forward.
Good news all around — except it didn’t last for long. After all, this is the U.S. health care system, where even patients with good insurance aren’t guaranteed affordable care.
To recap: For more than a decade, Nix, of Statesville, North Carolina, has suffered from autoimmune diseases, chronic pain, and fatigue, as well as a condition called trigeminal neuralgia, which is marked by bouts of electric shock-like pain that’s so intense it’s commonly known as the “suicide disease.”
“It is a pain that sends me to my knees,” Nix said in October. “My entire family’s life is controlled by the betrayal of my body. We haven’t lived normally in 10 years.”
Late in 2022, Nix started receiving intravenous immunoglobulin infusions to treat her diseases. She started walking two miles a day with her service dog. She could picture herself celebrating, free from pain, at her daughter’s summer 2024 wedding.
“I was so hopeful,” she said.
But a few months after starting those infusions, she found out that her insurance company wouldn’t cover their cost anymore. That’s when she started “raising Cain about it” on Instagram and Facebook.
You probably know someone like Sally Nix — someone with a chronic or life-threatening illness whose doctor says they need a drug, procedure, or scan, and whose insurance company has replied: No.
Prior authorization was conceived decades ago to rein in health care costs by eliminating duplicative and ineffective treatment. Not only does overtreatment waste billions of dollars every year, but doctors acknowledge it also potentially harms patients.
However, critics worry that prior authorization has now become a way for health insurance companies to save money, sometimes at the expense of patients’ lives. KFF Health News has heard from hundreds of people in the past year relating their prior authorization horror stories.
When we first met Nix, she was battling her insurance company to regain authorization for her infusions. She’d been forced to pause her treatments, unable to afford $13,000 out-of-pocket for each infusion.
Finally, it seemed like months of her hard work had paid off. In July, Nix was told by staff at both her doctor’s office and her hospital that Blue Cross Blue Shield of Illinois would allow her to restart treatment. Her balance was marked “paid” and disappeared from the insurer’s online portal.
But the day after the KFF Health News story was published, Nix said, she learned the message had changed. After restarting treatment, she received a letter from the insurer saying her diagnoses didn’t actually qualify her for the infusions. It felt like health insurance whiplash.
“They’re robbing me of my life,” she said. “They’re robbing me of so much, all because of profit.”
Dave Van de Walle, a spokesperson for Blue Cross Blue Shield of Illinois, said the company would not discuss individual patients’ cases.
“Prior authorization is often a requirement for certain treatments,” Van de Walle said in a written statement, “and BCBSIL administers benefits according to medical policy and the employer’s benefit.”
But Nix is a Southern woman of the “Steel Magnolia” variety. In other words, she’s not going down without a fight.
In September, she called out her insurance company’s tactics in a http://change.org/ campaign that has garnered more than 21,000 signatures. She has also filed complaints against her insurance company with the U.S. Department of Health and Human Services, U.S. Department of Labor, Illinois Department of Insurance, and Illinois attorney general.
Even so, Nix said, she feels defeated.
Not only is she still waiting for prior authorization to restart her immunoglobulin infusions, but her insurance company recently required Nix to secure preapproval for another treatment — routine numbing injections she has received for nearly 10 years to treat the nerve pain caused by trigeminal neuralgia.
“It is reprehensible what they’re doing. But they’re not only doing it to me,” said Nix, who is now reluctantly taking prescription opioids to ease her pain. “They’re doing it to other patients. And it’s got to stop.”
Do you have an experience with prior authorization you’d like to share? Click here to tell your story.
KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.
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What are the most common symptoms of menopause? And which can hormone therapy treat?
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Despite decades of research, navigating menopause seems to have become harder – with conflicting information on the internet, in the media, and from health care providers and researchers.
Adding to the uncertainty, a recent series in the Lancet medical journal challenged some beliefs about the symptoms of menopause and which ones menopausal hormone therapy (also known as hormone replacement therapy) can realistically alleviate.
So what symptoms reliably indicate the start of perimenopause or menopause? And which symptoms can menopause hormone therapy help with? Here’s what the evidence says.
Remind me, what exactly is menopause?
Menopause, simply put, is complete loss of female fertility.
Menopause is traditionally defined as the final menstrual period of a woman (or person female at birth) who previously menstruated. Menopause is diagnosed after 12 months of no further bleeding (unless you’ve had your ovaries removed, which is surgically induced menopause).
Perimenopause starts when menstrual cycles first vary in length by seven or more days, and ends when there has been no bleeding for 12 months.
Both perimenopause and menopause are hard to identify if a person has had a hysterectomy but their ovaries remain, or if natural menstruation is suppressed by a treatment (such as hormonal contraception) or a health condition (such as an eating disorder).
What are the most common symptoms of menopause?
Our study of the highest quality menopause-care guidelines found the internationally recognised symptoms of the perimenopause and menopause are:
- hot flushes and night sweats (known as vasomotor symptoms)
- disturbed sleep
- musculoskeletal pain
- decreased sexual function or desire
- vaginal dryness and irritation
- mood disturbance (low mood, mood changes or depressive symptoms) but not clinical depression.
However, none of these symptoms are menopause-specific, meaning they could have other causes.
In our study of Australian women, 38% of pre-menopausal women, 67% of perimenopausal women and 74% of post-menopausal women aged under 55 experienced hot flushes and/or night sweats.
But the severity of these symptoms varies greatly. Only 2.8% of pre-menopausal women reported moderate to severely bothersome hot flushes and night sweats symptoms, compared with 17.1% of perimenopausal women and 28.5% of post-menopausal women aged under 55.
So bothersome hot flushes and night sweats appear a reliable indicator of perimenopause and menopause – but they’re not the only symptoms. Nor are hot flushes and night sweats a western society phenomenon, as has been suggested. Women in Asian countries are similarly affected.
You don’t need to have night sweats or hot flushes to be menopausal.
Maridav/ShutterstockDepressive symptoms and anxiety are also often linked to menopause but they’re less menopause-specific than hot flushes and night sweats, as they’re common across the entire adult life span.
The most robust guidelines do not stipulate women must have hot flushes or night sweats to be considered as having perimenopausal or post-menopausal symptoms. They acknowledge that new mood disturbances may be a primary manifestation of menopausal hormonal changes.
The extent to which menopausal hormone changes impact memory, concentration and problem solving (frequently talked about as “brain fog”) is uncertain. Some studies suggest perimenopause may impair verbal memory and resolve as women transition through menopause. But strategic thinking and planning (executive brain function) have not been shown to change.
Who might benefit from hormone therapy?
The Lancet papers suggest menopause hormone therapy alleviates hot flushes and night sweats, but the likelihood of it improving sleep, mood or “brain fog” is limited to those bothered by vasomotor symptoms (hot flushes and night sweats).
In contrast, the highest quality clinical guidelines consistently identify both vasomotor symptoms and mood disturbances associated with menopause as reasons for menopause hormone therapy. In other words, you don’t need to have hot flushes or night sweats to be prescribed menopause hormone therapy.
Often, menopause hormone therapy is prescribed alongside a topical vaginal oestrogen to treat vaginal symptoms (dryness, irritation or urinary frequency).
You don’t need to experience hot flushes and night sweats to take hormone therapy.
Monkey Business Images/ShutterstockHowever, none of these guidelines recommend menopause hormone therapy for cognitive symptoms often talked about as “brain fog”.
Despite musculoskeletal pain being the most common menopausal symptom in some populations, the effectiveness of menopause hormone therapy for this specific symptoms still needs to be studied.
Some guidelines, such as an Australian endorsed guideline, support menopause hormone therapy for the prevention of osteoporosis and fracture, but not for the prevention of any other disease.
What are the risks?
The greatest concerns about menopause hormone therapy have been about breast cancer and an increased risk of a deep vein clot which might cause a lung clot.
Oestrogen-only menopause hormone therapy is consistently considered to cause little or no change in breast cancer risk.
Oestrogen taken with a progestogen, which is required for women who have not had a hysterectomy, has been associated with a small increase in the risk of breast cancer, although any risk appears to vary according to the type of therapy used, the dose and duration of use.
Oestrogen taken orally has also been associated with an increased risk of a deep vein clot, although the risk varies according to the formulation used. This risk is avoided by using estrogen patches or gels prescribed at standard doses
What if I don’t want hormone therapy?
If you can’t or don’t want to take menopause hormone therapy, there are also effective non-hormonal prescription therapies available for troublesome hot flushes and night sweats.
In Australia, most of these options are “off-label”, although the new medication fezolinetant has just been approved in Australia for postmenopausal hot flushes and night sweats, and is expected to be available by mid-year. Fezolinetant, taken as a tablet, acts in the brain to stop the chemical neurokinin 3 triggering an inappropriate body heat response (flush and/or sweat).
Unfortunately, most over-the-counter treatments promoted for menopause are either ineffective or unproven. However, cognitive behaviour therapy and hypnosis may provide symptom relief.
The Australasian Menopause Society has useful menopause fact sheets and a find-a-doctor page. The Practitioner Toolkit for Managing Menopause is also freely available.
Susan Davis, Chair of Women’s Health, Monash University
This article is republished from The Conversation under a Creative Commons license. Read the original article.
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How To Lower Your Blood Pressure (Cardiologists Explain)
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Today we enjoy the benefit of input from Dr. Zalzal, Dr. Weeing, and Dr. Hefferman!
If the thought of being in an operating room with three cardiologists in scrubs doesn’t raise your blood pressure too much, the doctors in question have a lot to offer for bringing those numbers down and keeping them down! They recommend…
150 mins of Exercise
This isn’t exactly controversial, but: move your body!
See also: Exercise Less; Move More
Reduce salt
Most people eating the Standard American Diet (SAD) are getting far too much—mostly because it’s in so many processed foods already.
See also: How Too Much Salt May Lead To Organ Failure
Eating habits
There’s a lot more to eating healthily for the heart than just reducing salt, and over all, the Mediterranean diet comes out scoring highest:
- What Is The Mediterranean Diet Anyway? ← a primer for the uncertain
- Four Ways To Upgrade The Mediterranean ← includes a heart-specialized version!
Reduce alcohol
According to the WHO, the only healthy amount of alcohol is zero. According to these cardiologists: at the very least cut down. However much or little you’re drinking right now, less is better.
See also: How To Reduce Or Quit Alcohol
Maintain healthy weight
While the doctors agree that BMI isn’t a great method of measuring metabolic health, it is clear that carrying excessive weight isn’t good for the heart.
See also: Lose Weight (Healthily!)
No smoking
This one’s pretty straight forward: just don’t.
See also: Addiction Myths That Are Hard To Quit
Reduce stress
Chronic stress has a big impact on chronic health in general and that includes its effect on blood pressure. So, improving one improves the other.
See also: Lower Your Cortisol! (Here’s Why & How)
Good sleep
Quality matters as much as quantity, and that goes for its effect on your blood pressure too, so take the time to invest in your good health!
See also: The 6 Dimensions Of Sleep (And Why They Matter)
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Sensitive – by Jenn Granneman and Andre Sólo
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This book is written for what is called the “Highly Sensitive Person”, which makes it sound like a very rare snowflake condition, when in fact the diagnostic criteria (discussed early in the book) yield a population bell curve of 30:40:30, whereupon 30% are in the band of “high sensitivity”, 40% “normal sensitivity” and the remainder “low sensitivity”. You may note that “high” and “low” together outnumber “normal”, but statistics is like that.
So, if you’re one of the approximately one in three people who fall into the higher category, and/or you have a loved one who is in that category, then this book looks at the many advantages to a commonly stigmatized and (by cruel irony) criticized personality trait.
Those advantages range from personal life to work and even public life (yes, really), and can be grown, positively highlighted, used, and enjoyed.
In the category of criticism, the book does not usefully cover the benefit of psychological resilience. Resilience does not mean losing sensitivity, just, being able to also dry one’s tears and weather life’s slings and arrows when the world is harsher than one might like. But for the authors, they have stacked all their chips on “we must make the world a better place”. Which is a noble goal, if not always an immediately attainable one.
Bottom line: if you are more sensitive than average and would like to use that to benefit yourself and those around you, then this is the book for you!
Click here to check out Sensitive, and make the most of your strengths!
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Tranquility by Tuesday?
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I Know How She Does It: How Successful Women Make The Most of Their Time
This is Laura Vanderkam, author of “Tranquility By Tuesday” (amongst other books). Her “thing” is spending more time on what’s important, and less on what isn’t. Sounds simple, but she’s made a career out of it, so condensed here for you are…
Laura’s 7 Keys To Productivity
Key One: Plan your weeks on Fridays
You don’t want your Monday morning to be a “James Bond intro” (where everything is already in action and you’re just along for the ride, trying to figure out what’s going on). So, take some time last thing each Friday, to plan ahead for the following week!
Key Two: Measure what matters
Whatever that means to you. Laura tracks her use of time in half-hour blocks, and likes keeping track of streaks. For her, that means running daily and keeping a log of it. She also keeps track of the books she reads. For someone else it could be music practice, or a Duolingo streak, or eating fruit each day.
On which note…
“Dr. Greger’s Daily Dozen” is simpler than most nutrition trackers (where you must search for everything you eat, or scan barcodes for all ingredients).
Instead, it keeps track of whether you are having certain key health-giving foods often enough to maintain good health.
We might feature his method in a future edition of 10almonds, but for now, check the app out for yourself here:
Get Dr. Greger’s Daily Dozen on iOS / Get Dr. Greger’s Daily Dozen on Android
Dr. Greger’s Daily Dozen @ Nutrition Facts
Key Three: Figure out 2–3 “anchor” events for the weekend
Otherwise, it can become a bit of a haze and on Monday you find yourself thinking “where did the weekend go?”. So, plan some stuff! It doesn’t have to be anything out-of-this-world, just something that you can look forward to in advance and remember afterwards. It could be a meal out with your family, or a session doing some gardening, or a romantic night in with your partner. Whatever makes your life “living” and not passing you by!
Key Four: Tackle the toughest work first
You’ve probably heard about “swallowing frogs”. If not, there are various versions, usually attributed to Mark Twain.
Here’s one:
“If it’s your job to eat a frog, it’s best to do it first thing in the morning. And if it’s your job to eat two frogs, it’s best to eat the biggest one first.”
Top Productivity App “ToDoist” has an option for this, by the way!
Laura’s key advice here is: get the hard stuff done now! Before you get distracted or tired and postpone it to tomorrow (and then lather rinse repeat, so it never gets done)
10almonds Tip:
“But what if something’s really important but not as pressing as some less important, but more urgent tasks?”
Simple!
Set a timer (we love the Pomodoro method, by the way) and do one burst of the important-but-not-urgent task first. Then you can get to the more urgent stuff.
Repeat each day until the important-but-not-urgent task is done!
The 10almonds Team
Key Five: Use bits of time well
If, like many of us, you’ve a neverending “to read” list, use the 5–10 minute breaks that get enforced upon us periodically through the day!
- Use those few minutes before a meeting/phonecall!
- Use the time you spend waiting for public transport or riding on it!
- Use the time you spent waiting for a family member to finish doing a thing!
All those 5–10 minute bits soon add up… You might as well spend that time reading something you know will add value to your life, rather than browsing social media, for example.
Key Six: Make very short daily to-do lists
By “short”, Laura considers this “under 10 items”. Do this as the last part of your working day, ready for tomorrow. Not at bedtime! Bedtime is for winding down, not winding up
Key Seven: Have a bedtime
Laura shoots for 10:30pm, but whatever works for you and your morning responsibilities. Your morning responsibilities aren’t tied to a specific time? Lucky you, but try to keep a bedtime anyway. Otherwise, your daily rhythm can end up sliding around the clock, especially if you work from home!
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The Anti-Viral Gut – by Dr. Robynne Chutkan
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Some people get a virus and feel terrible for a few days; other people get the same virus and die. Then there are some who never even get it at all despite being in close proximity with the other two. So, what’s the difference?
Dr. Robynne Chutkan outlines the case for the difference not being in the virus, but in the people. And nor is it a matter of mysterious fate, but rather, a matter of the different levels of defenses (or lack thereof) that we each have.
The key, she explains, is in our microbiome, and the specific steps to make sure that ours is optimized and ready to protect us. The book goes beyond “eat prebiotics and probiotics”, though, and goes through other modifiable factors, based on data from this pandemic and the last one a hundred years ago. We also learn about the many different kinds of bacteria that live in our various body parts (internal and external), because as it turns out, our gut microbiome (however important; hence the title) isn’t the only relevant microbiome when it comes to whether or not a given disease will take hold or be eaten alive on the way in.
The style is very polished—Dr. Chutkan is an excellent educator who makes her points clearly and comprehensibly without skimping on scientific detail.
Bottom line: if you’d like your chances of surviving any given virus season to not be left to chance, then this is a must-read book.
Click here to check out The Anti-Viral Gut, and make your body a fortress!
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Minimize Aging’s Metabolic Slump
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It’s Q&A Day at 10almonds!
Have a question or a request? We love to hear from you!
In cases where we’ve already covered something, we might link to what we wrote before, but will always be happy to revisit any of our topics again in the future too—there’s always more to say!
As ever: if the question/request can be answered briefly, we’ll do it here in our Q&A Thursday edition. If not, we’ll make a main feature of it shortly afterwards!
So, no question/request too big or small
❝I know that metabolism slows with age, are there any waypoints or things to look out for? I don’t know whether I should be eating less, or doing less, or taking some other approach entirely. What’s recommended?❞
Age and sex count for a lot with this one! As metabolism is in large part directed by hormones:
- For men, declining testosterone (often from around 45 onwards) can result in a metabolic slump
- For women, declining estrogen with the menopause does have an effect, but progesterone is the bigger factor for metabolism in the sense you are talking about.
In both cases, simply taking more of those hormones can often help, but please of course speak with an endocrinologist if that seems like a possible option for you, as your circumstances (and physiology) may vary.
If you’d like to go to that conversation well-armed with information, here are some good starting points, by the way:
- The Testosterone Drop, & Topping Up Testosterone
- Menopausal HRT: Bioidentical vs Animal (It Makes A Difference!)
And if you’re wondering about the natural vs pharmaceutical approaches…
- What Does “Balance Your Hormones” Even Mean?
- What You Should Have Been Told About The Menopause Beforehand
About your metabolic base rate
We tend to think of “fast metabolism good, slow metabolism bad”, and that’s a reasonable general premise… but it’s not necessarily always so.
After all, if you could double your metabolism and keep it there all the time, without changing anything else, well… You’ve heard the phrase “burning the candle at both ends”? So, having at least some downtime is important too.
See for example: Sleep Deprivation & Diabetes Risk
What’s critical, when it comes to base metabolic rate, is that your body must be capable of adequately processing what you are putting into it. Because if your body can’t keep up with the input, it’ll just start storing the excess chemical energy in the quickest and easiest way possible.
…which is a fast track to metabolic disorder in general and type 2 diabetes in particular. For more on the science and mechanics of this, see:
How To Prevent And Reverse Type 2 Diabetes
As for portion sizes…
Your body knows what you need, so listen to it. There is no external source of knowledge that can tell you how much food you need better than your own body itself can tell you.
You may be wondering “how exactly do I listen to my body, though?”, in which case, check out:
The Kitchen Doctor: Interoception & Mindful Eating
As for exercise…
When you exercise, your metabolic rate temporarily increases. After most kinds of exercise, your metabolism slumps again afterwards to compensate.
There are two ways to avoid this:
- Exercise Less, Move More ← it’s about maximizing time spent not sitting still
- High Intensity Interval Training ← a special kind of exercise, the only one known to keep the metabolism running high for a couple of hours afterwards, with no counter-slump
…which makes it pretty effective indeed
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