Asheville, NC, October 24, 2025
News Summary
John Middleton, a 43-year-old engineer from Asheville, North Carolina, battles a health insurance dispute that is delaying critical cancer treatment. Diagnosed with cholangiocarcinoma, he needs an FDA-approved drug, Ziihera, for his best chance of survival, but Cigna has denied the authorization, citing the need to try less effective options first. As he faces a grim prognosis, Middleton worries about his family’s future, including care for his pets and a potential liver transplant from his twin brother.
Asheville Faces Health Insurance Crisis for Terminally Ill Engineer
In Asheville, North Carolina, 43-year-old engineer John Middleton is struggling with a health insurance dispute that is delaying his urgently needed cancer treatment. Diagnosed with cholangiocarcinoma, a rare and deadly type of bile duct cancer, Middleton faces a grim prognosis and a fight not only against the disease but also against his insurance provider.
Cholangiocarcinoma affects approximately 8,000 people in the U.S. each year, and the survival rate for this condition is daunting, with only 22% of patients surviving five years post-diagnosis. Middleton estimates he has around 18 months to live unless he receives effective treatment that can keep his cancer in check.
Middleton’s oncologist, Dr. Martin Palmeri, has advised that his best chance of survival is through a liver transplant, which is contingent upon managing his cancer effectively for six to nine months. His identical twin brother, James, is willing to donate a liver, making the transplant a feasible option.
To control the cancer, doctors have recommended Ziihera, an FDA-approved drug specifically targeting the genetic profile of Middleton’s cancer. However, after Dr. Palmeri contacted Cigna Healthcare in March to obtain prior authorization for Ziihera, the request was denied, as Cigna requires that he first try other, less effective medications.
Two subsequent appeals made on behalf of Middleton were also denied. A spokesperson for Cigna stated that the request was thoroughly reviewed by multiple medical directors with specialties in Hematology and Medical Oncology. Cigna eventually approved another drug, Enhertu, but medical experts consider this option to be significantly less effective and not suitable for Middleton’s urgent needs.
Dr. Palmeri has classified Enhertu as “grossly inferior” to Ziihera, indicating that it may not provide the necessary control over Middleton’s cancer for successful transplant eligibility. Middleton has begun treatment with Enhertu but reports feelings of disappointment as it was not the drug recommended by his healthcare team.
Typically, cholangiocarcinoma is diagnosed late, resulting in high mortality rates; however, in Middleton’s case, a chance MRI for Crohn’s disease enabled early detection. He has previously undergone various cancer treatments, including surgery, chemotherapy, and radiation. He was cancer-free until his recurrence in February 2023.
Clinical trials show that Ziihera could offer a response rate of over 50%, with median effects lasting around 15 months, making it the optimal choice for Middleton’s condition. Cigna’s refusal was partially based on the stipulation that one must have undergone HER2 therapy before qualifying for Ziihera, which contradicts clinical trial parameters.
Middleton’s family is at the forefront of his concerns as he worries about the impact of his condition on them, including his pets. His bond with his twin brother is particularly strong, with the two communicating daily and sharing dreams of living closer together in the future.
Impact of Cholangiocarcinoma
- Cholangiocarcinoma diagnosis rate: 8,000 cases per year in the U.S.
- Five-year survival rate: 22%
- Middleton’s estimated life expectancy: 18 months without effective treatment.
Key Treatment Details
| Treatment | Drug | Effectiveness |
|---|---|---|
| Recommended | Ziihera | Over 50% response rate, median effects lasting about 15 months |
| Approved by Cigna | Enhertu | Considered less effective according to multiple medical assessments |
FAQs
What is cholangiocarcinoma?
Cholangiocarcinoma is a rare and deadly type of bile duct cancer that approximately 8,000 people are diagnosed within the U.S. each year. The prognosis for this cancer is poor, with only 22% of patients surviving five years post-diagnosis.
What treatment does John Middleton need?
John Middleton has been advised that his best chance of survival is through a liver transplant, which requires him to manage his cancer effectively for six to nine months. His healthcare team has recommended Ziihera, an FDA-approved drug tailored to his cancer’s genetic profile.
Why did Cigna deny the treatment authorization?
Cigna denied the authorization for Ziihera, stating that Middleton needed to try alternative, less effective medications first. Subsequent appeals for authorization were also denied, leading to challenges in Middleton’s treatment plan.
What is the response rate for Ziihera?
Clinical trials indicate that Ziihera can achieve a response rate of over 50%, with median effects lasting about 15 months, making it a potentially optimal option for managing cholangiocarcinoma.
Deeper Dive: News & Info About This Topic
HERE Resources
Escalating Political Violence in America
UNC Asheville Receives Historic $5 Million Donation
Asheville’s Ongoing Recovery from Hurricane Helene
Asheville City Schools Propose No-Cut Budget for 2025-26
Pregnant Mothers in Asheville Face Healthcare Crisis Amid Storm Devastation
Asheville Faces Ongoing Water Crisis Amid Boil-Water Advisory
Asheville Businesses Face Uphill Battle After Hurricane Helene
Additional Resources
- NBC News: Liver Transplant & Drug Needs
- Cancer Therapy Advisor: Natural Disasters and Cancer Care
- U.S. News: Mission Hospital
- Carolina Journal: Central Planning Fails in Health Care
- WYFF: Asheville Fentanyl & Meth Trafficking
- Wikipedia: Cholangiocarcinoma
- Google Search: Cholangiocarcinoma
- Google Scholar: Cholangiocarcinoma Treatment
- Google News: Cholangiocarcinoma
Author: STAFF HERE ASHEVILLE WRITER
The ASHEVILLE STAFF WRITER represents the experienced team at HEREAsheville.com, your go-to source for actionable local news and information in Asheville, Buncombe County, and beyond. Specializing in "news you can use," we cover essential topics like product reviews for personal and business needs, local business directories, politics, real estate trends, neighborhood insights, and state news affecting the area—with deep expertise drawn from years of dedicated reporting and strong community input, including local press releases and business updates. We deliver top reporting on high-value events such as the Asheville Bread Festival, LEAF Festival, and mountain sports tournaments at Biltmore Estate. Our coverage extends to key organizations like the Asheville Area Chamber of Commerce and Explore Asheville Convention & Visitors Bureau, plus leading businesses in hospitality and brewing that power the local economy such as the Biltmore Estate and Sierra Nevada Brewing Company. As part of the broader HERE network, including HERECharlotte.com, HEREGreensboro.com, HERERaleigh.com, and HEREOBX.com, we provide comprehensive, credible insights into North Carolina's dynamic landscape.
