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I-Team: Losing Formula

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There are kids here in Wisconsin with chronic conditions. Their bodies can't process food without getting sick. Only one thing lets them live a somewhat normal life. Still, many insurance companies won't pay for it because they don't have to. But that may soon change.

Melody McCabe of Waukesha is a mom on a mission.

"The child has no voice, and you are its voice, and you are your child's advocate," McCabe explained.

At 6-months-old, her son, Andrew, suddenly stopped putting on weight and always appeared in to be pain.

"Why is he always constipated? Why is he throwing up at night," McCabe wondered. "Why are meal times so hard?"

Andrew ended up at Children's Hospital of Wisconsin.

"We thought if we gave him more calories, which is more food, he would grow," said Dr. Praveen Goday, Gastroenterologist and Director of CHW's Nutrition Program. "They tried giving him more food and all our usual tricks, but it didn't seem to work."

After tons of tests, doctors discovered that Andrew has a chronic disease called Eosinophilic gastroenteritis. Basically, Andrew's bowel is full of allergy cells. Eating food, any food, makes those cells flare up and makes Andrew very very sick.

"We were feeding him poison and had no idea," McCabe said.

Turns out, the only thing Andrew's body can process, without getting sick, is a special synthetic formula called "Neocate." The ingredients are already in their simplest form and easy to digest.

"It's is great to see him start bulking up, starting to get the muscle mass he needs, because at the time, he was malnourished and we didn't even know it."

To get the nutrition he needs, Andrew drinks the Neocate from a baby bottle. If he doesn't drink enough, he gets more through a feeding tube while he sleeps.

"Unfortunately, at night, he'll sometimes hook his hand into the tube if it's not taped well, he'll pull it out," McCabe said. "We'll know because he'll start gagging and coughing when it comes out."

But the biggest challenge: Neocate is expensive, $30 to $50 per can. Andrew goes through one can every two days. The bigger he gets, the more he'll need.

"Right now the only way we've been able to afford the formula is friends and family." McCabe said. "It's not like we have all this extra money to throw around."

Making matters worse, their insurance company, UnitedHealthcare, won't pay for the Neocate, because the McCabe's policy doesn't cover it.

"Here I am trying to spend all my energy focusing on my child who's sick, and learning all these different things on how to make him better, and then on top of that, I have to fight the insurance company," McCabe said.

Even after Dr. Goday went to bat for Andrew, UnitedHealthcare still denied an appeal.

"We want the insurance companies to do their jobs and take care of kids' therapies," Goday said. "My job is to advocate what therapy is needed."

Dr. Goday says there are no other options.

"This is the only known therapy for Andrew," Goday asserted. "There's no other therapy. It's not just food"

Maybe most frustrating, in cases like Andrew's, 14 other states already have laws on the books which require insurance companies to pay for the special formula, including Illinois and Minnesota. Wisconsin still doesn't.

"It is a no-brainer for anybody in my position," Goday said.

And after the I-Team told him about Andrew's case, state Representative Jon Richards of Milwaukee, who chairs the Assembly's Heath Committee, agreed.

"I think this is something that we need to address when we come back from the session in January," said Richard.

Richards plans to push a bill to get Wisconsin in line with its neighbors.

"In something like this, where you have an unusual condition with catastrophic results, people should make sure that they're covered, and people should be covered for it," Richards argued.

Richards now wants a mandate to make sure families in Wisconsin, with kids like Andrew, can afford something those kids literally can't live without.

"If he doesn't take this, he withers away," said McCabe. "Unfortunately, he fails to thrive, he starts deteriorating, and he'd probably die."

That's all the motivation McCabe needs to keep up her crusade.

At this point, Andrew needs the Neocate indefinitely. His doctor says new medicines are being developed to treat his condition, but it could be years before they're on the market. That's why Andrew's mom is turning up the heat on lawmakers to require insurance companies to pay for the formula here as they do in other states.

 

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