An important note by Dr. Lewis S. Blevins, Jr., Medical Director, California Center for Pituitary Disorder and Co-Founder, Pituitary World News. I’m losing my patience with insurance companies and pharmacy benefit managers. They are destroying medicine in their pursuit of wealth for investors and C-suite executives. Many things we do, from diagnostic and laboratory tests to medications, are being denied. The work we must do to advocate for our patients and gain approval for things that are medically necessary has become overwhelming. And that is exactly by design. They are betting that doctors and patients will simply give in to their cost-controlling tactics so that more money flows to dividends rather than to health care.
I was once asked to conduct physician reviews on behalf of a company that reviewed requests for an insurance company. At the time, I thought it might be an opportunity to make a positive difference and to help patients get the treatment they needed. I was impressed that they would ask an expert to help sort out the requests for expensive treatments. I was wrong. I was told that I would be expected to deny 75% of requests. It was made crystal clear that I would be graded and face termination if I allowed too many approvals. The decision to approve or deny had nothing to do with medicine. It was a quota. I told them the equivalent of a good old southern saying: “Go jump into the lake.”
Let me show you what this looks like in practice with a real case so you can understand my frustrations.
I have a patient with ACTH-independent hypercortisolism due to adrenal hyperplasia. He does not have a pituitary tumor. His adrenal glands are the source of his hypercortisolism. I prescribed levoketoconazole, which is an appropriate medication for his condition. They denied. We appealed with clear descriptions justifying our request. They denied again after a so-called physician reviewed the request and our appeal. Their doctor, who is supposed to deny most things, said we couldn’t use the drug we had chosen. We were told we must use the formulary alternative at every step.
Their alternative recommendation? Signafor, which is a drug approved specifically for patients with ACTH-secreting pituitary tumors. My patient does not have that condition! He has adrenal hyperplasia, and the biochemical data indicate that his pituitary is not part of this setting at all. Sigh.
This is the letter I suggested my office send in response:
-
- “This patient has ACTH-independent hypercortisolism due to adrenal hyperplasia. He DOES NOT have a pituitary tumor.
- I’ve prescribed levoketoconazole. You disapproved and then also denied an appeal.
- You have said he should try Signafor, which is a drug approved for patients with ACTH-secreting pituitary tumors. HE DOES NOT HAVE THAT CONDITION!
- Your insistence on Signafor is much like suggesting that I treat a bacterial infection with a medication to lower blood pressure. IT MAKES NO SENSE WHATSOEVER!
- I strongly request that you approve the medication requested and refrain from insisting that we use a medication that is NOT INDICATED for his medical condition.
- If you’d like, I’d be pleased to educate your reviewing physician, who seems to have little knowledge of this matter.”
What else can we do? This is not just one patient’s story. This is happening every day to patients across every diagnosis in endocrinology. Diagnostic scans are denied. We even must get authorization for Synthroid! It has become rather complex to even select appropriate therapy for patients in need of testosterone. Individualization of therapies for patients with acromegaly? Forget about it!
I strongly urge you to be vocal and protest any insurance denials of testing and medical care prescribed by your qualified medical professionals. We must work together to protect the relationship between patients and doctors so we can do what is medically necessary without outside influence. Individually, a voice is barely even heard. Together, we can make a lot of noise! Write your insurance companies. Have an attorney write a letter, too. Call the insurance company and complain. Write your senators and congressmen and women.
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Thank you for speaking out on this topic and sharing your frustration. Without this knowledge, I would not have the confidence to stand up to the insurance company.
This work is so important and I applaud your efforts!
As convenient timing woudl have it, Dr Myiesha Taylor (an activist for women’s, and really for anyone not-young-healthy-white-male’s, health), just posted:
https://pituitaryworldnews.org/its-time-to-do-something-about-insurance-companies-trying-to-play-doctor/
TL;DR – to bear the insurance company’s “we deny everything we can” automatons:
“The physicians who win these calls do something different:
They ask what criteria set is being used (i.e. what boxes are on your screen that I have to check)?
They lead with documentation, dates, and objective findings (to check those boxes on your screen).
And if the answer is still no, they ask exactly what would change the determination (so you know what those boxes are so next time you call, you can say the thing).”
Obviously, having to do this is wrong. The steps however might be useful to share with physicians who haven’t already figure it out.
I am beyond frustrated that some AI bots in some dystopian “healthcare insurer”, can practice medicine without a license and literally kill people. I am completely convinced that I will someday die because some insurance company doesn’t want to spend the money to pay for a treatment I should be entitled to. At this point I’m so completely frustrated, that I’m not sure it wouldn’t be a relief.