A Northfield woman has won her appeal to have a potentially lifesaving liver transplant covered by her health insurance.
Medical Mutual of Ohio recently reversed its original decision and agreed to cover a liver transplant for Jeanne Ralston-Astalos.
“I could finally breathe,” she said. “That was such a hurdle. It’s such a relief.”
Ralston-Astalos, 50, is battling an extremely rare form of cancer that started in her sinuses and spread to her liver.
Medical Mutual initially refused to cover the procedure, which it classified as an “investigational/experimental” treatment for her condition and therefore not covered under her insurance policy.
An independent physician specialist reviewed Ralston-Astalos’ appeal and additional details provided by her doctors at Cleveland Clinic, Dr. Robert Rzewnicki, Medical Mutual’s chief medical officer, said on Monday.
The reviewer concluded a liver transplant “would be a reasonable and proper treatment for this individual, for this very uncommon tumor,” Rzewnicki said.
“We really do want what’s right for the individual,” he said. “We’re not interested in denying necessary care or denying appropriate care. That’s why we encourage people to push ahead with the appeal process as expeditiously as possible and to work with their provider to give us additional information we can send along to the reviewers.”
Ralston-Astalos has been told the cost for her transplant ranges from $300,000 to $500,000.
Medical Mutual is the third-party administrator for the self-insured plan that provide health coverage for Ralston-Astalos. With self-insured plans, the employer pays the bills but contracts with an administrator to oversee coverage and handle claims.
In September 2012, Ralston-Astalos underwent surgery at MD Anderson Cancer Center in Texas get rid of the primary cancer by removing the roof of her mouth, half of her jawbone, teeth and most of her sinus cavity. She now relies on a prosthetic palate and oral piece to eat, drink and talk.
Since that surgery, the area around her sinuses has remained cancer free. Extensive testing has shown no other signs of cancer throughout her body, except for slow-growing, metastatic cysts in her liver.
Unusual case
The cancer, ameloblastoma, usually doesn’t spread beyond the sinuses, said Dr. Nizar Zein, chief of hepatology and medical director of liver transplantation at the Cleveland Clinic. Only a few similar cases have been documented worldwide.
Because the cancer has spread to both sides of her liver, surgical removal of the tumors isn’t an option, Zein said.
“The tumor burden is quite impressive that there is no opportunity to do local chemotherapy or radiation therapy,” he said. “The only opportunity to cure the cancer is going to be by removing the liver in its entirety.”
Other successes
The Cleveland Clinic provided Medical Mutual evidence that transplants have been used to successfully cure some metastatic liver cancers involving tumors similar to Ralston-Astalos’, Zein said.
Those patients fared as well as everyone else undergoing liver transplants at the Cleveland Clinic, Zein said. The hospital’s one-year survival rate for liver transplant recipients is nearly 92 percent.
“We believe the outcome is going to be good,” Zein said. “She wants to live, and she wants to fight for her life. I think she will have a good outcome in the end. She has a very supportive family. She has a very positive attitude.”
A group of Ralston-Astalos’ friends are continuing to plan fundraisers to help her pay for copays, deductibles and other costs she’ll face. They previously had been trying to raise $500,000 in case she didn’t win her appeal.
Information is available online at jeannetransplant.wix.com/jeanne-ralston-astalos-fund. Donations to the Jeanne Ralston-Astalos Fund also are accepted at any Key Bank location.
Ralston-Astalos will be placed on the waiting list for a cadaver liver as soon as all the paperwork is received confirming her transplant is covered, Zein said. She also could be a candidate for a living donor transplant if a match can be found who’s willing to give up a portion of the organ.
“Technically, we’re classifying it as we won a battle, not the war yet,” she said.
For more information about becoming a living organ donor for patients in need of a transplant, call the Cleveland Clinic at 216-445-8473.
Cheryl Powell can be reached at 330-996-3902 or cpowell@thebeaconjournal.com. Follow Powell on Twitter at twitter.com/CherylPowellABJ.