Aug 14, 2026
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Add us on GoogleIn 2025, Americans spent $5.6 trillion on health care, and that number is projected to climb to as much as $8.6 trillion by 2033. For some patients, the biggest financial burden comes after their insurance claim is denied.
That’s what happened to 26-year-old Payton Herres. The heart transplant survivor was left without coverage for a critical drug — and it took viral social media posts and attention from billionaire Mark Cuban for her to finally get more affordable access to it.
Herres’s story
Herres underwent a heart transplant when she was just a preteen. One year after her surgery, she began taking a prescription drug called everolimus, a generic version of Novartis’s anti-rejection drug Zortress, off-label.
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Her insurance provider, Elevance Health, told her last year that it would no longer cover the drug. That’s when she took to Facebook to share her story.
“I didn’t know what else to do,” she told Marketwatch in an interview. Her post was shared thousands of times. A day after posting, her coverage was restored, but at a much higher price. Instead of the $180 she used to pay, she was now being charged $1,000 per 90-day supply.
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“I call that ghost approval. Technically, you approved it,” Herres told Marketwatch. “But I still can’t realistically get the med because you [made] it financially impossible to get.”
Her story then went viral a second time. This time The Independent published a story on Mary Cutter. Her 24-year-old son, an only child, died in 2012, and his heart was donated to Herres. Cutter had offered to pay for the drug so Herres could keep taking it. According to Marketwatch, someone posted the story on social media, tagging Warris Bokhari, CEO and co-founder of Claimable, an AI startup, and former Shark Tank judge Mark Cuban.
“This is beyond incredible,” Cuban wrote in response to one of Herres’ posts on LinedIn. “Approve and pay for the heart transplant. Deny the generic rejection medicine.”
Cuban’s pharmacy stepped in, and now supplies Herres’ medication for about $300 for 90 days. A nonprofit associated with Bokhari’s startup is covering the costs.
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The rising rates of denials
Unfortunately, Herres’ situation is becoming increasingly common. According to a recent study from IQVIA, a health care consulting firm, 70% of commercially insured patients were initially denied coverage for at least one newly prescribed branded medicine in 2024. Nearly a quarter of patients were left unable to gain approval for any new prescriptions after a year. And it’s not just prescriptions being denied. A study from the Commonwealth Fund found 21% of U.S. working-age adults with private insurance reported that they or their family member experienced denial for medical care recommended by a doctor. Among those who experienced a denial, nearly 70% said it cost them or their households more money.
According to Commonwealth, denials can happen for a variety of reasons, including billing errors and administrative issues. Coverage can also be denied if a treatment or procedure is deemed medically unnecessary or if it’s delivered by an out-of-network provider.
In Herres’ case, Elevance Health told Marketwatch that the denials “did not fully account for Ms. Herres’ treatment history with everolimus” and that the drug she takes is considered a specialty medication and costs more.
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What to do if you’re rejected
Having your insurance claim rejected can be stressful, scary and confusing. But there are things you can do to fight the rejection.
You have the right to appeal the rejections if your claim is denied. You can ask your insurer directly to conduct a review of the decision. You also have the right to appeal the decision to a third party for external review.
It’s important to understand why you were rejected and to gather evidence showing your policy and coverage before filing your appeal. If your appeal is unsuccessful, you can file a complaint with your state insurance commissioner.
Having an emergency savings fund can also help protect you when coverage is denied. Medical bills are a leading cause of bankruptcy for Americans and having money set aside can help protect your finances and ensure vital treatment isn’t being delayed.
In the case of Herres, an emergency savings fund may not be enough to cover long-term medication expenses, but it will still provide a cushion to cover you while you figure out your options.
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Rinna Diamantakos is an assigning editor at Moneywise.com. A versatile journalist, she has experience as a writer, editor and producer. Her work has focused on politics, business and financial news.
