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 coated a mixed distance that’s practically equal to working the size of Manhattan 4 occasions.
By the top of the month, she was in a hospital mattress.
Hvatum, a part-time laptop science professor, has a weakened immune system attributable to a uncommon situation referred to as main immunodeficiency, which makes it tough for her physique to combat infections. Previous to her 2005 prognosis, she had 4 bouts of shingles, a painful rash attributable to a virus.
For greater than a decade she relied on an costly drugs to deal with her continual 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 house, close to St. Louis, Hvatum can administer the advanced drugs herself. She makes use of a big syringe to attract the drugs 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 gradual drip of the drugs, and it snakes via plastic tubing till it enters her leg via a needle.
The Invoice
$8,141.94: The total fees for a 28-day provide of Hizentra with out insurance coverage protection.
After her Medicare Benefit plan via Humana denied cost for the drug in January, she missed a number of weekly doses.
The Billing Drawback: Prior Authorization
Hvatum received tousled within the controversial course of referred to as prior authorization, which frequently requires sufferers or their medical workforce to get an insurance coverage firm’s approval earlier than acquiring medicines or remedy.
Firstly of the 12 months, after Hvatum switched Medicare Benefit plans, she acquired a letter saying that Humana, her new provider, had denied her “prior authorization prescription request” for Hizentra. The authorization from her earlier insurer didn’t carry over.
With out the drugs, Hvatum developed a urinary tract an infection that despatched her to the emergency room on Jan. 30. Although it’s a frequent an infection, her physician suggested her to go there as a result of individuals together with her situation can get sick and deteriorate rapidly, she mentioned.
That ER go to was an in a single day hospital keep. That was hospital fees 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 shouldn’t be distinctive.
Medicare Benefit plans reviewed practically 53 million prior authorization requests in 2024, in accordance with KFF. That’s equal to just about two critiques for each individual enrolled in this system.
It’s frequent for Medicare Benefit plans to disclaim cost for care — which helps them make a revenue, mentioned Carrie Graham, director of the Medicare Coverage Initiative at Georgetown College’s Middle 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 revenue if the care that individual receives in that 12 months is lower than the quantity they obtain,” Graham mentioned.
Greater than half of eligible Medicare beneficiaries select Medicare Benefit insurance coverage protection. In 2026, roughly 35 million chosen certainly one of these non-public insurance policies provided by insurance coverage firms.
Humana is a dominant participant within the area. Almost half of all Medicare Benefit enrollees nationwide are coated by UnitedHealth Group or Humana, in accordance with KFF.
The killing of UnitedHealthcare CEO Brian Thompson prompted renewed scrutiny of prior authorization. Final summer season, months after his dying, 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 companies that may 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 mentioned this pledge to honor current approvals comes with limitations. “These commitments are for medical companies solely and don’t apply to prescription medicines,” spokesperson Mark Taylor mentioned.
Humana declined to touch upon the specifics of Hvatum’s case, despite the fact that 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 mentioned it “builds vital checks and balances into the healthcare system by verifying that therapies and care supply are in the most effective curiosity of affected person security and high quality of care, whereas safeguarding taxpayer {dollars}.”
In July 2025, Humana mentioned it might take away one-third of prior authorization necessities for outpatient companies.
“We’re dedicated to creating the method quicker and extra seamless for sufferers and suppliers,” Humana mentioned in a press release Taylor supplied 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 drugs once more.
However the approval got here with a catch: It expires on the finish of the 12 months, after which she would wish to acquire approval another time.
Hvatum has since switched to a distinct drug — and she or he 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 might 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 performed her half. Operating is her outlet, possibly an obsession, and it retains her wholesome. Scores of medals and trophies are tucked about her house. 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 grasp from ribbons of all colours, made to look nearly like customized window material.
“I’ve performed the whole lot I presumably can to be wholesome,” Hvatum mentioned, sitting at her eating room desk in her working gear. Her printed T-shirt learn, “If discovered on floor, please drag throughout the end line.”
The Takeaway
Information exhibits sufferers ought to enchantment prior authorizations, as a result of those that do usually get their denials reversed, Graham mentioned. In actual fact, 81% of Medicare Benefit appeals had been partially or totally overturned in 2024, in accordance with KFF.
Comparatively few individuals enchantment, as a result of “it’s an exhausting course of,” Graham mentioned. It places the onus on sufferers — and medical doctors 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 nicely versed in submitting appeals. She submitted one other enchantment 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 authorised her Hizentra, she mentioned, she might have averted 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 suppose she would wish to remain not less than two nights, the edge 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 like to ship you the denials quick,” Hvatum mentioned. “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 decreased, and it has been cited in statehouses, on the U.S. Capitol, and on the White Home. Do you’ve a complicated or outrageous medical invoice you need to share? Inform us about it!
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