Clinic Students Win Insurance Appeal for Life-Prolonging Drug By Nicole Soucy Doctors said he would die by the end of 2007. “My husband would not be alive today if it wasn’t for the Health Law Clinic,” said Faith Hazelton. Faith’s husband, Edward J. Hazelton, has terminal, irreversible brain cancer. After they were initially denied coverage, they turned to the law school’s Health Law Clinic to help them persuade Empire Blue Cross and Blue Shield to pay for Edward’s chemotherapy—a treatment that cost $42,000 a month. Fight for Coverage
After several different treatments were unsuccessful, Hazelton’s doctor, Susan Weaver, requested approval of insurance coverage for the cutting-edge treatment Avastin/CPT 11—which was originally developed to treat colon cancer. Empire Blue Cross refused. Dr. Weaver tried several more times unsuccessfully. Knowing Hazelton had a limited window of opportunity, she referred the Hazeltons to the Health Law Clinic in May 2007. Professor Joseph Connors, director of the Health Law Clinic, and students Donald J. Labriola ’08 and Daniel M. Lindenberg ’08 took on the case. The Clinic’s initial informal attempts to resolve Hazelton’s coverage dispute were unsuccessful. “The insurance company would not even consider reviewing coverage before Mr. Hazelton received treatment,” explained Professor Connors. “He had to pay out-of-pocket for the treatment.”
As a result of the insurance company’s decision, the Hazelton’s literally went doorto-door soliciting donations to come up with a down payment for the cancer treatments. The Hazelton’s community in Glens Falls, N.Y., even held fundraisers at the local high school to pay for his treatments. “One of my treatments was delayed a week just so I could scrape together $8,000,” he explained. The good news was the chemotherapy was working. Although his long-range prognosis remained terminal, the chemotherapy could help him live his remaining years pain-free. On Sept. 6, 2007, the Clinic submitted the appeal for insurance coverage of the treatment Avastin/CPT 11. The letter included cited reports of “impressive results” of Avastin’s alternate use found by the Brain Tumor Center at Duke University Medical Center. It also explained how the chemotherapy had improved Hazelton’s quality of life and likely expanded his time with his family and friends. In an affirmation document accompanying the Law School appeal, Dr. Weaver said the “experimental” usage of cancer drugs—Avastin/CPT 11 in particular—“has become very common among neuro-oncologists across the country and is routinely approved by other insurance companies.” Six days later, Empire Blue Cross approved the treatment, finding it “medically necessary,” and would provide coverage
Cancer patient Ed Hazelton surrounded by, from left, Donald J. Labriola ’08, Ed’s wife Faith Hazelton, Daniel M. Lindenberg ’08 and Professor Joseph Connors. for Hazelton’s past and future treatments. Medical-Legal Collaboration
With the Health Law Clinic’s recent successful case, Professor Connors says the medical-legal collaboration not only helps resolve legal disputes, but leads to improved health outcomes for clients. “Doctors and lawyers working together can achieve what neither can alone.” The students who worked on this case—Donald J. Labriola ’08 and Daniel M. Lindenberg ’08—are planning on a career in health law. Labriola even plans to launch his own poverty law agency in Albany. “I want to focus my practice on representing HIV/AIDS patients facing discrimination and helping the elderly with insurance problems.” Aftermath
Months after the Clinic won the Hazelton case, Avastin/CPT 11 was approved by the FDA to
treat breast cancer. The FDA still has not approved the treatment for brain cancer. In order to reach out to other patients in similar insurance disputes, the Clinic posted many of the documents relating to the Hazelton case on the clinic’s Web site at www.albanylaw.edu/clinic. Since then, Professor Connors has received a number of emails from individuals who are using the medical research conducted by Lindenberg and Labriola to support their own insurance appeals. As for Hazelton, he is feeling much better. He’s doing so well that he and his wife went to Florida in February for vacation.
“My husband would not be alive today if it wasn’t for the Health Law Clinic.” 5