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Oncotype DX Test and Insurance

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Posted 5/16/2005 10:46 PM (GMT 0)

Questions, questions, questions.....

I'm curious to find out if anyone's insurance company paid for their Oncotype DX test.  

Was the claim paid immediately or did you have to fight with the insurance company?

If you did have to fight with the insurance company, what information did you provide to convince them to pay?

What insurance company and state?

Any infomation is greatly appreciated.  I had the test done (glad I did) but the insurance company does not want to pay.   I know Genomic Health is engaged in the battle on my behalf but I have to get my two cents in as well.  I'm looking for some additional ammo before I write my appeal letter.

Thanks.

Marianne  

Posted 5/17/2005 1:58 PM (GMT 0)
OK Marianne, you managed to post another new thread and everyone is answering on the other one including me. LOL. But this might attrack some new people, too as a key word in the title. Since this test is so new only the newly diagnosed would have even had minimal access to it. Many of us are old timers. I had a mastectomy eight years ago when I was 58 and that was all the treatment I had. All my doctors including an oncologist said I did not need further treatment because the pathology was good. So most likely I would have scored very low on the test. It would have been good to have been able to have had it then, tho. Keep after the insurance company, I know they will pay since they paid for Mias. Hugs MK
Posted 5/17/2005 10:58 PM (GMT 0)

Hi Mk,

I guess I need to venture back over to the other thread.  LOL!

First of all, congratulations on the eight years!  No chemo, no tamoxifen . . . nothing?  That is wonderful.

I am not going to give in to the insurance company easily, that's for sure.  I do hope this thread attracts some new people willing to share their experience with their insurance company regarding the test.

Marianne

Posted 5/18/2005 2:27 PM (GMT 0)
No Marianne I was told by PC, surgeon and an oncologist I did not need chemo. My path report was about as low as it can be, thankfully. It likely had to do with my age and history of benign lumps. When my daughter was diagnosed two years after me, tho, I really began to worry that maybe I should have had something. She was advised she needed to go through chemo as a preventative for future, since she was only 39. I was given a Tamoxifen Rx but given a choice of taking it or not. After struggling with the side effects for six months I decided I chose not to take it. She was also prescribed Tamoxifen but had really bad depression while on it, which is never a problem for her normally. So she also quit taking it. So far we are both doing fine. Hope it all works out for you fine, too. Hugs MK
Posted 5/18/2005 4:47 PM (GMT 0)
Marianne-
I work in the managed care industry for mental health and substance abuse area, so not much experience in the medical claims side of things. But a lot of times a high up HR person or Benefit manager at the employer contacts me to override a benefit. So, depending on how you have your insurance and how the employer is set up. You may be able to run appeals up that tree too. In the case of a self-insured plan, like from a large employer, the employer, or customer, can trump the insurance co's decision.

And like MK said, not too many of us have experience with this, it is so new and we've been around the block a few times....
Good luck!
Lori
Posted 5/18/2005 10:41 PM (GMT 0)
Hi Lori,

I am definitely going to appeal their decision.  Hopefully they will cover it fo me and for other breast cancer patients who decide to be tested.  I feel that $3,500 is a small price to pay considering chemo would have cost them ten times more.

Thanks.

Marianne

 

Posted 5/18/2005 10:47 PM (GMT 0)
Hi MK,

I started the Tamoxifen two weeks ago and was ready to flush them down the toilet last night. Seems the side effects are starting to kick in and I don't like it one bit! I understand your decision not to take it. I know many women who had breast cancer ten, twelve, eighteen and twenty years ago who did nothing but surgery and radiation and are fine today. I think you made the right decisions.

Wishing you and your daughter continued success,

Marianne
Posted 5/19/2005 2:56 AM (GMT 0)
Hi Marianne,
This is Jean in WA writing about the Oncotype DX test. I had posted a couple of months ago about my experience getting the test approved by my insurance company. They, too, bulked at the test cost, and said the test was still considered "investigational". However, I did a lot of searching the internet and found that at the San Antonio Breast Cancer Symposium in December 2004 had two entities validate the GenomicHealth Lab's work. The New England Journal of Medicine and Kaiser Permanente both did studies and found the information to be valid. Armed with this information, and the fact that I was the perfect candidate for the test, I confronted the insurance company. They finally agreed to pay for the test as though the Lab was a non-preferred provider, at 60%. That meant I still had to pay 40%, but $1350 is a lot better than $3500! My insurance company is Premera Blue Cross of Washington and Alaska, and I live in Washington. Do you have a case manager with your company? I was given the opportunity to have one, whom I can call on whenever I have a question. She helped to present this backup documentation to their doctor board, who make the decision to pay or not.

Good luck to you! And as you said, they would smart to pay for this test, and possible elimiate tens of thousands of dollars in chemo treatments.

Take care, Jean in WA
Posted 5/19/2005 4:13 AM (GMT 0)
Hi Jean in WA. 

I can't thank you enough for sharing your story and ideas.  I am in the process of putting a package together for the insurance company and you mentioned some really great stuff to include. 

These boards are great!

Thanks again.

Marianne

Posted 5/19/2005 4:19 AM (GMT 0)
Jean,

One more thing . . . good work! Sounds like you did a great job convincing your insurance company to pay the claim. You paved the way for so many others as well.

I know I'd settle for 60%!

Marianne
Posted 5/19/2005 2:16 PM (GMT 0)
Good Morning Marianne,
Thanks for the thanks! Yes, I was the first that my insurance company agreed to pay for the test. I am still waiting for a final bill from Genomic Health, but expect at least to have to pay $1300 or so. I guess Premera negotiated with the lab for a lesser rate (a few hundred less??).

I was interested in MK deciding not to take the hormone therapy after her surgery. And also that you were given Tomoxifen. Are you post-menapausal? If you are, my research (here I go again!) indicates that Arimidex is the therapy of choice for those of us who are post-menapausal, estrogen positive, early stage breast cancer. It is supposed to have fewer side affects than the standard Tomoxifen. Anyway, I have five more radiation treatments to go (had to delay a week since I am very red), but hopefully, I will be done by May 27...my graduation day! Then, I meet with the medical oncologist to "discuss" my followup treatment. I have already told him my choice...we shall see if he agrees! If not, I may be making another trip to Spokane to see my "second opinion" doctor, who agrees Arimidex is best for me.

My advice is to keep pushing your insurance company and do the research for them. Just type in Oncotype DX in the search engine on-line, and you will find tons of information and backup for your claim.

Take care! Jean in WA
Posted 5/20/2005 11:19 PM (GMT 0)
Jean,

I'm jealous . . . rads are almost over for you.  I just finished my 14th day of radiation.  I'm a little pink and a bit swollen which makes one side a lot perkier than than the other.  Are you getting the boosts now?

I am pre-menopausal at 48 so that is why they prescribed Tamoxifen for me.  Although I had pretty much made up my mind not to do chemo, the Oncotype DX test gave me further justification for my decision.  FYI, my bc was IDC, 1.2 cm., Stage 1, Grade 2; highly ER/PR +, HER2 -, low s-phase, Ki-67 showed low proliferation rate, diploid tumor, no vascular, no perineural and no lymphatic invasion, no necrosis and Nottingham Score of 6 (mitotic count - 1; nuclear pleomorphism - 2; and tubule formation - 3).  All the docs said it was a really well-behaved, slow growing tumor and for that I am thankful. 

You really sound like you did your homework when it came to researching breast cancer and your options.  Knowledge is power!  I couldn't stop reading for weeks.  Happy I stumbled upon this site.

I'll be counting down the days with you.

Marianne

Posted 11/9/2005 11:48 PM (GMT 0)

Hi, Marianne

I am a new survivor (received the diagnosis on March 14, 2005) and I had the test done in May 2005.  My insurance company at first denied the test as not medically necessary.  Genomic Health and my oncologist sent letters in to appeal.  My insurance company then said they were denying the claim because the test appeared to be experimental  mad

I have been trying to find documentation that the test is no longer experimental.  According to Genomic Health, the test has been on the market for two years.  I even tried contacting the American Cancer Society today (11/09/05) and was referred to Patient Advocate Foundation.  I tried calling them and have not heard back yet.  I even called my oncologist's office and found out my doctor is out of the office this week  scool

I intend to do my appeal letter tonight and let my insurance company know that documentation should be forthcoming.  I don't think I have an easy fight ahead - my insurance will have to foot the entire bill because I met my out-of-pocket maximum for the year in April.

Good luck on your fight! 

Pattie

Posted 11/10/2005 1:47 AM (GMT 0)

Hi Pattie,

I am still fighting the insurance company.  My insurance company is saying the same things as yours.  I'm not giving up yet though.  My hope is someone else will respond with some great info we can use.  If you happen to run across anything saying it is not experimental please let me know.  I will do the same.

Good luck with your fight as well. 

Marianne

Posted 11/10/2005 3:36 PM (GMT 0)
Hi Ladies,

I, too, am in the appeals process to get the test paid for. One thing I found out from Genomic Health is that the reason the test is considered experimental is because the "powers that be" haven't given it a medical code, so they have to bill the insurance companies without a "real" medical code. The insurance companies don't like that and so they deny the claim. If the medical board that assigns these codes would hurry up and assign the code, our insurance companies would be more willing to pay. This was verified in a conversation to my insurance company who told me they won't pay unless there is a "real" code.

Maybe it is another entity we need to be pressuring. I just don't know who approves codes - the AMA? FDA?

But, I'm going to keep fighting to get it paid for. I was told prior to the test that I would need chemo, but the test proved I was not a good candidate for chemo. I'm thrilled to have been able to find that out through a simple test!

Take care!
Laure'
Posted 11/12/2005 10:22 PM (GMT 0)
Wondering how all of you are doing in getting action from the insurance company. It seems to me this test would be cheaper for them in the long run if more test out not needing chemo. Don't give up, that is what insurance companies expect you to do, then they win. Hugs, MK
Posted 11/17/2005 11:54 AM (GMT 0)
Hi Marianne,
I would just like to let you know that Genomic Health, Inc. has programs available to assist you with your appeals. If you haven't already done so, please contact our GAP program at 877-235-4349. There is also a lot of valuable information on reimbursement on our website www.genomichealth.com.
We appreciate your support of Oncotype DX and are pleased to hear that it was of value to you and your physician in making such an important treatment decision.
Our best wishes to all of you.
Rina
Posted 11/18/2005 4:00 PM (GMT 0)

Marianne:

As you may remember, I had contacted my oncologist's office to obtain "reliable evidence" that the Oncotype Dx test is not experimental.  When I got home last night, there was an envelope from that office.  Guess what was inside?  Two articles from the New England Journal of Medicine.  tongue

I haven't had time yet to read the articles, but I believe they will be what I need.  After I review, I will be sending them to my insurance company.  Would you like copies?

Best of luck!

Pattie

Posted 12/7/2005 10:56 PM (GMT 0)

Hi, Everyone!

I am still fighting with my insurance company over them paying for this test.  They upheld their decision on second appeal - they even said The New England Journal of Medicine showed the test was experimental.  Add to this the fact that my case was reviewed by a Nephrologist (kidney doctor) rather than an oncologist.  You can imagine how angry and frustrated I am.  mad

I am not giving up yet, though.  I've already started working on the third appeal.  After rereading some of the posts on this thread, I am considering contacting my Benefits person to see if they can help me.  My insurance company is self-funded.

If this third appeal fails and I have no other recourse, the next thing my insurance company will hear from me will be through a lawyer.  I hate to go that route, but . . .

Posted 12/8/2005 12:19 AM (GMT 0)
Hang in there Pattie and keep fighting. You might document the companies who have paid and present that to yours in this third appeal. I think most of the girls have said what company they had that paid. Good luck, Hugs MK
Posted 12/26/2005 3:16 PM (GMT 0)
Hello Ladies,
I have been absent from this site for quite some time now. Guess now that I am feeling better, I am not as alert to others' needs. Sorry about that!

On the Oncotype DX test fees...my insurance company finally paid the entire bill! As I said, I kept pushing and wouldn't take no for an answer, and they really could not call the test "investigational" any longer. My insurance company is Premera Blue Cross of Washington and Alaska.

Good luck, and you might want to refer your company to Premera.

Jean in WA
Posted 12/26/2005 11:18 PM (GMT 0)
Nice to see you stop by and offer support and information. I hope you won't be missing for so long again. You have good experiences to share just like this one. Hope 2006 is a great year for you and yours, MK
Posted 1/5/2006 7:25 AM (GMT 0)
Hi Everyone!

I wanted to update you on my insurance appeals regarding the OncotypeDx test.  United Healthcare of Florida agreed to pay 70%!!!!!  I was thrilled upon receiving the news today.  

My persistence finally paid off!

Genomic Health is still going to appeal for the remaining 30%.

Good luck to all of you who are currently in the appeals process.  Don't give up too easily.

Happy New Year to all,

Marianne

 

Posted 1/5/2006 2:29 PM (GMT 0)
Great news, Marianne! I'm thrilled for you. Thank you from all of us still in the "fighting" process since you have definitely helped many women with your persistence! Kudos!

Happy New Year to You!

Laure'
Posted 1/5/2006 8:57 PM (GMT 0)

Congratulations, Marianne, on getting your insurance to pay.  I haven't sent in my third appeal yet - holidays, etc.

For those of you still fighting (like I am), I found something that might help.  The National Cancer Institute (www.cancer.gov) produces a bulletin and I found a write-up on the Oncotype Dx test in the December 14, 2004, issue (vol. 1, Number 48).

I figure I've had enough time to "cool off", so I am going to go over the letter I wrote in early December and edit it.  I plan on telling my insurance company that other insurances have paid (I will include names of companies), another copy of the articles I received, as well a copy of the NCI Bulletin.  Hopefully, this will work.

I also contact my HR person back in December to see if they could help.  I hadn't heard anything as of today, so I e-mailed them again - still waiting.

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