Denial of payment prompts battle

A transplant would give him a 75 percent to 80 percent chance of survival.
By HAROLD GWIN
VINDICATOR STAFF WRITER
NEW CASTLE, Pa. -- Sam Swartz spent Aug. 1 in Pittsburgh getting last-minute tests for a blood stem cell transplant that could save his life, but when he got home, he learned his insurance company had decided not to finance the procedure.
Swartz, 44, of Neshannock Township, was diagnosed with leukemia 21/2 years ago and found out four months ago that the medicine he was taking to combat the disease wasn't working.
His oncologist told him he needed a stem cell transplant, a process in which his blood cells are killed with chemotherapy and replaced with healthy cells from a donor.
Without the transplant, the doctor gave him a life span of 18 months to two years. With it, he stands a 75 percent to 80 percent chance of survival, Swartz said.
A search for a donor through national and international donor banks turned up nothing, and the family decided to begin testing relatives to find a match.
It turned out that Lori Bible of Hermitage, a registered nurse at UPMC Horizon, was a prime candidate, matching five of six tissue and cell tests.
Bible said that Swartz's transplant surgeon said that because she is Swartz's first cousin and comes from the same bloodline, they are a good match. Any problems with that sixth missing match could be overcome with medication.
Turned down
Swartz said his insurance company, HealthAmerica-HealthAssurance, was aware of all the transplant preparations, paying for his tests and for those of potential donors.
He anticipated no problems with the company's picking up the transplant cost, which is expected to range between $500,000 and $1 million, when he went to the Western Pennsylvania Hospital on Aug. 1 for final tests.
His doctor immediately sent the paperwork to the insurance company, and Swartz headed for home.
"By the time we got home, they'd turned it down," Swartz said, adding that he is appealing that ruling.
An insurance company representative told him that Bible isn't a close enough match and that having her serve as a donor makes the transplant an experimental procedure that the company won't pay for, he said.
HealthAmerica-HealthAssurance issued a statement to The Vindicator saying that, because of confidentiality issues, it can't discuss the details of individual cases with anyone not directly associated with the individual's care or the immediate family.
The Vindicator got no response to a request for information on the company's general policy regarding transplants.
Raising money
Swartz said that if his appeal is unsuccessful, he can sue the insurance carrier while he and his family try to raise money for the transplant themselves.
The hope would be that the hospital would agree to do the procedure with some money up front and a promise to pay the rest, he said.
His illness has made it impossible for him to continue his job as an outside sales representative, he said.
Time is running out.
Swartz's leukemia is in what is referred to as an accelerate stage, which means it is getting worse. Once it reaches the acute stage, his chance of survival even with the transplant drops dramatically, he said.
Bible's hope
The news that the insurance company won't pay for the transplant dismayed Bible, 37.
She said she was honored to find out that she was a match for her cousin and is anxious to move ahead with the transplant.
It's so rare to be able to give someone another chance at life, she explained.
Bible, who has been a nurse for 15 years, said she feels helpless in the current situation but is doing what she can, including working through the director of UPMC Horizon's oncology department to try to get the transplant back on track.
Swartz said his battle against the disease has been hard on his wife, Billie Jean, who has been researching the disease and the donor search, and their four children ages 24, 18, 16 and 14.
"They don't know what's going to happen," Swartz said, adding, "They're scared I'm not going to make it."
As for his outlook?
"I'm confident," he said. "I'm surely going to fight it."
gwin@vindy.com