The San Francisco Chronicle - Thursday, July 29, 1999
Tom Abate, Chronicle Staff Writer

Senechek is a Harvard-trained physician, a San Francisco AIDS specialist whose patient list includes 600 people suffering from the wide array of HIV-related afflictions.

Blue Shield, a not-for-profit health plan based in San Francisco, insures more than 2 million Californians. It has voluntarily instituted an external review program so patients and doctors can challenge denials of coverage.

Now Senechek is questioning Blue Shield's refusal to pay for a drug he has prescribed for an AIDS patient who agreed to be identified only by his first name.

Kelly came to Senechek a year ago suffering from a rare and virulent disease called mucormycosis. It is a fungus, possibly carried by moldy old wood, that can infect the sinus cavities of people whose immune systems have been weakened by AIDS. Once inside the sinuses, mucormycosis dissolves bone and skin in both directions.

"Imagine all your teeth falling out and an infection one centimeter from your brain," Senechek said.

Blue Shield had no problem paying for the surgery to cut away the infected areas and the drug treatments Kelly underwent to eliminate any lingering traces of the fungus.

But earlier this month, after he wrote an unusual prescription, Blue Shield balked. Senechek wanted to give Kelly three doses of a drug called Proleukin to boost his immune system and to ward off any infection that survived the treatment.

Senechek estimated the Proleukin might cost $3,000. Blue Shield's chief medical officer Al Martin said the experimental nature of the prescription triggered the review, which has, so far, resulted in denial.

"The decision to review had nothing to do with dollars," Martin said. "Proleukin is a very powerful drug with lots of potential side effects and very specific indications for its use."

Proleukin was approved in 1992 to fight cancer, but is likely to be useful in treating other diseases. In a recent article in the Journal of Infectious Diseases, AIDS researchers reported that Proleukin boosted the immune systems of 25 HIV patients.

When Blue Shield denied the treatment, Senechek cited this study to bolster his contention that the drug would strengthen Kelly's immune system against a relapse.

Blue Shield, following its own procedure, asked an outside medical expert to review the dispute. The expert decided Proleukin "has not been shown to be of any benefit" for mucormycosis and upheld the denial.

Blue Shield has now asked an independent law firm to choose a second panel of experts to conduct an external review of the denial.

But Senechek questions the review process because the identities of the reviewers are confidential. He has treated hundreds of AIDS patients and wants to be assured that the "experts" on the panel know at least as much as he does.

Martin said reviewers have to remain anonymous or they would not agree to participate. "They don't want to be caught up in a situation where they are lobbied by us, the patient or the physician," he said. Walter Zelman, president of the California Association of Health Plans, said the state Legislature is almost certain to enact a bill mandating an external review process like Blue Shield's. But the details are far from settled.

Jamie Court, a patients' rights advocate with the Foundation for Taxpayer and Consumer Rights, said reviewer anonymity is an issue legislators need to address. "Anonymity breeds a lack of accountability," Court said.

As the patient involved, Kelly has a simpler view. He said Senechek prescribed Proleukin to make his immune system strong enough to undergo surgery to rebuild his jaw so he can chew.

"I'm 43 years old, and I don't want to eat pureed foods for the rest of my life," he said.
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