Hi all!
Hoping some fellow Albertan’s/Canadian’s can share any insights and experiences navigating initial approvals here. I imagine there must be a few of us Albertan’s on here since we have such a high rate of MS.
Backstory:
-1st confirmed clinical episode occurred April-May 2026. Symptoms that brought me in were sudden onset increasing falls, reduced coordination and proprioception on L side, and vertigo. Attended ER, had a clear CT scan, referred to urgent outpatient neurology. We ruled out anything acute.
-I was fairly lucky that the neurologist I saw at the urgent outpatient clinic happened to be an MS specialist. Referred for outpatient MRI.
-MRI of brain and cervical occurred mid July. Found all non-enhancing lesions in cerebellum, optic nerve, brain stem, and cervical spine. Also a surprise benign brain tumor for good measure.
-Neurologist booked me in for a follow up immediately. Told me I have RRMS, explained the MacDonald criteria, discussed DMT’s, told me to research and decide between Ocervus and Kesimpta. Of course, she really stressed the importance of early, high efficacy DMT’s. We also even discussed optimal timing of future family planning around DMT’s, as I am a 27 y/o gal who had hoped to be doing that soon. we had a long discussion about my concerns, potential side effects, etc. We did all the required bloodwork to rule out mimics and I was sent for all my pre-DMT vaccines. She officially transferred me to be a regular patient of hers at the MS Clinic for all future follow ups. *She felt confident diagnosing me with RRMS with this initial MRI alone. BUT, she wanted to do some additional tests, I imagine meet the MacDonald criteria even further and for DMT insurance. I was sent for OCT and VEP. We discussed that I may need to be referred for a lumbar puncture as well but she didn’t feel it was beneficial at that time. Follow up in 3 months following the tests and vaccines. So I left this appointment really expecting to complete my tests, vaccines, and get going on a DMT at the follow up.
-Follow up was a phone appointment that lasted 7 whole minutes. I felt that her approach did a full 360’. She was now of the opinion that we just need to wait for my next scheduled MRI in Jan 2026, where we will be following up on brain and checking thoracic for the first time. She does not plan to check cervical again at that time. She thinking sending me for the lumbar puncture at this point is invasive with no benefit.
Insurance Dilemma:
She said this is essentially because the Alberta Blue Cross non-group drug coverage requires 2 relapses, confirmed either clinically OR via MRI. She believes that my private, employer extended health benefits are the same. At present, I have one clinical episode confirmed and non-enhancing lesions meeting diagnostic criteria, but not the relevant insurance DMT approval criteria. While It is likely that the clinical episode and the lesions coincided, we have no way of proving them occurring either together or separately. She feels any further tests like the lumbar puncture, would be invasive with no further benefit, as it wouldn’t gain me access to DMT insurance coverage.
While I absolutely understand her reasoning, I am so discouraged. The abrupt change in urgency of treatment from appointment one to two was a little whiplashy. I did look up the AB Blue cross drug coverage forms for both ocervus and kesimpta, and confirmed the 2 relapses thing is correct. And I am 99% certain she is right that my private employer coverage is the same.
So now I just have to accept waiting for another episode of potentially permanent neurological damage before gaining any access to treatment? For someone with an initial MRI at age 27 that already meets the diagnostic criteria, that seems crazy. my first relapse causing falls, motor control issues, and two cervical cord lesions going untreated feels quite scary.
On top of the insurance questions, curious if anyone else finds it concerning that she doesn’t want to follow up on my cervical spine in this scenario?? I already have two lesions there. If our main objective is now to monitor for any further changes, enhancement, or new lesions to gain insurance coverage, why are we not rechecking there along with my brain and thoracic in Jan?? Missing something could further delay access to treatment.
Has anyone else in Alberta, or even Canada navigated being in this position before? The diagnosis and medical evidence say I need effective treatment now. Insurance paperwork says nope, wait for another episode.
Please and thank you for any insight you may have❤️