Miami judge orders insurer to cover cancer patient’s $48K drug. Here’s what to know

A Miami-Dade judge ordered Oscar Health Insurance to authorize and pay for a Stage 4 pancreatic cancer patient’s recurring $48,500 oral medication. The ruling could help other patients fighting insurers over treatment denials.

FULL STORY:Son hopes dad’s legal win in Miami spares cancer patients from fighting insurers

Here are key takeaways:

• The ruling: Miami-Dade Circuit Judge Migna Sanchez-Llorens ordered Oscar Health to cover Pablo Langesfeld’s prescribed cancer drug. Oscar Health has up to 30 days to appeal.

• The dispute: The fight began in December when Langesfeld’s in-network doctor prescribed Avmapki Fakzynja Co Pack after failed chemotherapy. Oscar Health repeatedly denied coverage, saying the drug wasn’t medically necessary or federally approved for pancreatic cancer.

• The drug: The medication is FDA approved for ovarian cancer and received “orphan drug” designation in 2024 for pancreatic cancer research. The National Cancer Institute notes many cancer drugs are effective against more than one type of cancer.

• Why the judge ruled this way: Sanchez-Llorens called parts of Oscar Health’s policies, including its definition of “medically necessary,” ambiguous. Florida law requires ambiguous insurance contracts to be interpreted in favor of the customer.

• A father’s message: “This is not just about me, it’s about helping other people being able to get treatment,” Pablo Langesfeld told the Miami Herald. He is also known for memorial efforts honoring his daughter and son-in-law, victims of the Surfside building collapse.

• Advice for other families: “Once an insurance company denies you two or three times, that’s not the end,” said Martin Langesfeld, Pablo’s son. “If you are in a situation like we were, fight it. Fight it because you can.”

• Industry changes: Major insurers, including Cigna, Aetna and United Healthcare, last year pledged to require pre-authorization for fewer procedures and speed up reviews.

This report was produced with the assistance of a proprietary tool powered by artificial intelligence and using our own originally reported, written and published content. It was reviewed and edited by our journalists.

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