A patient at Downey Hospital is denied a necessary medication before open heart surgery because of religious preference. Epogen (Epoetin Alfa) is used to elevate a patient’s hemoglobin levels within the recommended levels of 10 to 12 g/dL.

The patient is 65 year old resident from South Gate (a low income area of east Los Angeles County). She is retired, a U.S. Citizen, and on a fixed income. The cost of the medicine is $380.00 per dose. At (7) doses it draws close to $2660.00. An amount difficultly paid for by a senior citizen on a monthly fixed income of $744.00. She had a heart attack last Wednesday evening and was rushed to Downey Regional Medical Center ER. She was found to have (3) clogged arteries in her heart. She was stabilized in the intensive care unit and preparations began for heart surgery at Good Samaritan Hospital, which has a Transfusion Free Surgical Center where “bloodless” surgery is routinely performed including open heart surgery. Due to religious beliefs, blood transfusion during surgery is not an option. Epogen is also used to treat blood transfused patients. Celida has been given (7) more days before surgery – low blood count or not. She is need of this medication due to a blood loss incident at the hospital which lowered her blood count. The chances of a patient undergoing open heart surgery are better when there are elevated blood levels. The quicker she can get her hemoglobin levels the quicker she can have Heart Surgery and the better her chances of living out her final years in good quality.

The insurance company, Scan Health plan, initially approved (4) doses of the (7) doses ordered by the cardiothoracic surgeon and cardiologist team, but later recanted and denied all doses stating, “It’s not a common drug” and “is only being requested because she’s a Jehovah’s Witness”.

According to the manufacturer, indication for use of the drug is to treat anemia (low red blood cell count) due to chemotherapy, anemia due to chronic renal failure, and for surgical procedure. Per the staff at the operating hospital (Good Samaritan hospital of Los Angeles) the drug is not uncommon in the use of open heart surgery patients with low blood counts.

The Downey Hospital Case management team and Physicians’ team have been fighting for the patient from the initial denial. Yesterday they appealed the insurance company decision which then re-denied it within 24 hours.

The Physician's office will attempt one more time and formally appeal to the insurance to pay for this NECESSARY medication so she can have this life-saving operation.

UPDATE:

October 17, 2008

Scan Healthcare has agreed to pay for and prescribe the Epogen medicine per a phone call made to Applecare medical group earlier Tuesday afternoon.   According to the family, after a 3rd review of the patient's case and the cardiothoracic surgeon's appeal, the insurance has declared that "medical necessity" has been established.     She will wait for the open heart surgery until her hemoglobin levels raise to over 13 g/dL, which with the Epogen, should be early next week, stated M.D. Lee.