![\"A](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/03\/1772577313_909_.jpeg\"\/)
<\/p>\nEliza Cowey was just 12 years old when she was diagnosed with an extremely rare brain cancer in 2022. In the four years since then, she and her family have been strapped into an emotional rollercoaster as Eliza goes through surgeries, scans, chemotherapy and radiation \u2014 not to mention puberty.<\/p>\n
A gut-wrenching turn in the track came late last year when a scan revealed that Eliza\u2019s cancer spread to a new part of her brain: an inoperable one.<\/p>\n
\u201cSome of the growth had come back and one of them was in a place that was not\u2026 accessible,\u201d said Eliza\u2019s mother Jody Handley. \u201cAnd that\u2019s been our fear \u2014 that she would get it in a place that we couldn\u2019t really reach.\u201d<\/p>\n
Eliza\u2019s astroblastoma is so rare that many of her care options are experimental. Bloodwork revealed a genetic marker that made her a good candidate for a pair of chemotherapy drugs that could slow the growth of the tumors. Jody said the treatment plan at this stage isn\u2019t focused on curing Eliza\u2019s cancer but extending the time she has left.<\/p>\n
\u201cWe\u2019re looking at buying time,\u201d she said. \u201cWe are not looking at curing this anymore.\u201d<\/p>\n
The new chemo drugs were the latest effort to buy more time. But before Eliza\u2019s doctor could administer them, he needed to get prior authorization from Aetna.<\/p>\n
Prior authorization requires doctors to get approval from a patient\u2019s insurance company before they\u2019ll cover a procedure, prescription or a service such as an imaging exam. Insurance companies use the process as a cost-control tool to prevent unnecessary, high-cost or inappropriate care.<\/p>\n
But who determines whether care is appropriate?<\/p>\n
Dr. Ed Balaban, a retired oncologist, said prior authorization requests require doctors and patients to navigate a complex approval pathway that can result in delayed or denied coverage for care. Different insurance companies have different authorization pathways. The process can even vary among different plans under the same insurer. And Balaban said when it came to denials, he was often left in the dark about why his treatment plan wouldn\u2019t be covered.<\/p>\n
\u201cYou never really knew why things were denied,\u201d Balaban said. \u201cIt wasn\u2019t a conversation; it was a mandate.\u201d<\/p>\n
Prior authorization can be particularly burdensome for cancer patients who often need urgent treatment or symptom management. That includes Eliza Handley.<\/p>\n
Aetna approved one of the new chemo drugs Eliza\u2019s doctors wanted to try. But they denied the second one. Children\u2019s Hospital of Pittsburgh explained to Jody that they must be taken together.<\/p>\n
After the denial, Jody got to work. She made call after call to Aetna, trying to navigate the appeals process for the prior authorization. Eliza\u2019s doctor worked on the appeal from his end while Jody kept the phone ringing at Aetna with every spare moment.<\/p>\n
She found the process demoralizing and stressful. Jody said it felt like her daughter\u2019s life was in the hands of an insurance company rather than a medical provider.<\/p>\n
\u201cPeople behind a phone who have no skin in the game; who don\u2019t know that [Eliza is] an amazing artist; who don\u2019t know that she\u2019s a very kind person who loves horror movies and Adventure Time,\u201d she said.<\/p>\n
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Kiley Koscinski<\/p>\n
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90.5 WESA<\/p>\n
Eliza’s pill planner sits next to her artwork in the Handley’s kitchen.<\/p>\n
Part of the appeal process requires a peer-to-peer call between a treating physician and a third-party doctor hired by the insurance company. But the insurance company\u2019s doctor won\u2019t always have the same training as the treating physician, according to Balaban.<\/p>\n
\u201cIt was very rare that I would actually be talking to another medical oncologist,\u201d Balaban said.<\/p>\n
In Eliza\u2019s case, her doctor made an appointment to speak with Aetna, but the call never came. It\u2019s unclear if the company called and left a voicemail. UPMC declined WESA\u2019s request for comment and did not make Eliza\u2019s doctor available for an interview.<\/p>\n
But Jody said since the doctors didn\u2019t connect, the authorization was denied. She worried that people falling through a gap like this isn\u2019t a flaw in the system, but part of its design.<\/p>\n
\u201cThat is a system that is designed to fail expecting that a pediatric neuro-oncologist has two and a half hours in his week that he can just set aside in his office and wait for a phone call that might not even come,\u201d Jody said.<\/p>\n
She took her frustration to social media where she heard from several families having similar experiences. One user introduced her to Mike Gartner, the founder of Persius, a Philadelphia-based organization that helps people appeal their insurance coverage denials.<\/p>\n
Jody shared her struggle with Persius and although she had already appealed the denial, the group was still able to help by drafting a report that laid out why Aetna should cover the chemo drugs.<\/p>\n
\u201cWe produced a letter that was roughly 11 pages by the next day which summarized the argument of the oncology team but also summarized the contractual language in this particular health plan,\u201d Gartner said.<\/p>\n
Together with Jody and Children\u2019s Hospital, Persius got Eliza\u2019s medication approved. And according to the data, that shouldn\u2019t be a surprise: the overwhelming majority of prior authorization denials are overturned on appeal, according to the American Medical Association<\/a>.<\/p>\n But few people appeal their prior authorization requests. Just one in eight denied requests were appealed in 2024, according to KFF<\/a>.<\/p>\n Kiley Koscinski<\/p>\n \/<\/p>\n 90.5 WESA <\/p>\n Eliza and Jody sit on the couch in their Squirrel Hill home while Eliza works on an illustration on her iPad.<\/p>\n Gartner said Persius was created to change that statistic. The organization offers free help to people navigating how to appeal an insurance company\u2019s decision to deny coverage. Gartner said he started the organization after experiencing his own coverage denial.<\/p>\n \u201cIt\u2019s really crazy that there\u2019s a need for this sort of service,\u201d he said. \u201cBut I don\u2019t foresee this problem going away anytime soon.\u201d<\/p>\n Last year, the nation\u2019s major health insurers \u2014 including CVS Health\u2019s Aetna and UnitedHealthcare \u2014 pledged to scale back the number of claims subject to prior authorization<\/a> and increase the number of claims for which responses can be completed in real time.<\/p>\n![\"Eliza](\"https:\/\/www.newsbeep.com\/nz\/wp-content\/uploads\/2026\/03\/1772577313_329_.jpeg\"\/)
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