Why does Medicare pay, but my Medicare Advantage plan won't ?

Hi all:

I was diagnosed with prostate cancer, the latter part of last year.

I have a Medicare Advantage plan with Health America Advantra.  It is my understanding that traditional Medicare pays for proton therapy for prostate cancer...seemingly with no problems.  But my Health America Advantra recently denied approval for me to have proton therapy for at the University of Penn.  I thought if Medicare approves a particular treatment (in this case Proton therapy), that all Medicare Advantage companies, by law, must also pay for that treatment.  In my case, that isn't happening...and I'm not sure why not.  It seems impossible to actually speak to the people at the insurance companies, who actually make the approval decisions.

I have heard and read form several sources that most insurance companies cover proton therapy in addition to Medicare.  I guess I unknowingly picked a bad Medicare Advantage insurance company.  As soon as I can, I'm going to be dropping my Health America Advantra Medicare Advantage policy for another insurance company that does cover proton therapy, or just go with Medicare Part A & Part B + a perscription plan + supplimental insurance.  I have heard Medicare + the supplimental plans give much better coverage then Medicare Advantage plans anyway...although at a higher cost.  Plus I understand Medicre + supplimental will allow me to go to other states for proton treatment, where I am stuck in one state with my Medicare Advantage plan.  Since Medicare + supplimental allows treatment in other states, that means I would be able to go to Loma Linda in CA for proton treatment.  I live in PA, but I sure would go to Loma Linda if my insurance allowed it.  Again, my lousy insurance won't even allow me to get proton treatment within my own state.

I was told by my insurance company that they won't pay for the proton treatment since they say it is investigational/experimental.  Maybe it is, and maybe it isn't.  I don't see how since Loma Linda has been doing it since 1990.  But if Medicare pays, then I figure my Medicare Advantage insurance should, BY LAW, be required to pay...with no "foot dragging".  My doctor even had a peer to peer review the other day with my insurance company and they still denied it.  Does anyone have any idea whats going on here?  My insurance company must have some kind of loophole.

My prostate was removed in Dec. 2011.  I was put on lupron while I healed up from the surgery.   Some of the cancer came through the prostate.  23 lymph nodes were biopsed, and no cancer was found.  I have had 3 bone scans and they were negative also...yipee.

However, since a little cancer came out of the prostate, my urologist wanted me to get radiation to get rid of any bad cells that might have got out.  I wanted proton treatment, but it looks like I will be stuck with IMRT.

Does anyone have any idea how a Medicare Advantage insurance company can legally deny me getting proton treatment, while Medicare does allow proton treatment?

Is there anyone else here that has been denied proton treatment by their Medicare Advantage insurance company?  Was that company Health America Advantra?  Which Medicare Advantage insurance companies DO authorize proton therapy?  I want to switch to one of those.

I thank you all for your input on this.

Bob

Bob,

I would respectively suggest that you not be so put off by the situation of choosing Proton versus IMRT/Photon.   There is absolutely no proof that Proton is any better.    IMRT is very effective with limited side effects.   The suggestions that Proton is more effective and with less side effects are unproven.   Since it has been in use for twenty years, it remains surprising that the Proton supporters haven't proven the case.

This, I believe, is why many insurance companies won't pay for it.   It is 3-4 times the cost and simply doesn't do any better than IMRT.  I suggest you spend your time and energy in a positive way by finding the best IMRT provider close to home and get on with the treatment.

As I understand, private insurance is not forced to pay for something just because Medicare has approved it for their payment eligibility.   Often, private insurance will say if Medicare doesn't pay, then neither will we, but I do not think that private insurance is forced to pay just because Medicare does.    With that being said, if it is so important for you to have Proton rather than IMRT, then it looks like dropping the Medicare Advantage and enrolling into Part B would be the solution.  

There have recently been several threads on proton, but I don't remember anyone discussing how that type of plan paid.

I am still in the employee/private insurance world, so can only add that my (big national) insurance company allows proton for some specific cancers, but for PCa, it is considered experimental, and not covered. They consider IGRT/IMRT to have equivalent outcomes.

Hi all:

I thank you all so much for your input.  I apologize for not responding sooner.  After I got back from church today I had to get some things done around the house.  If my wife doesn't give me any work to do I will respond...lol.

First of all I wish you all the very best for the "club" we reluctantly were forced to join.  I will try to remember to pray for you all as a group each day.

Hi Steve:  Fortunately I will be able to easily change insurance companies since I am on Medicare.  But it can only be done at certain times each year.  It's my understanding there are no problems with the Medicare insurance companies, with pre-existing conditions.

Hi JNF:  Yep...I will be getting a CAT scan tomorrow, in preparation for IMRT.  I'll start IMRT as soon as possible.  My urologist wanted me to wait til some time in April to start the radiation so that I could heal from the prostate removal surgery.  I assume that is a normal time to wait?  I hope it wasn't too long.  I have been on Lupron for about 8 or 9 months. 

I had a robot work on me.  It looked like the robot beat me up during surgery...lol.  I noticed I was black and blue all over after I woke up from the surgery. 

I assumed the proton therapy was as effective as IMRT, but had fewer side effects.  But since my pelvic bed needs to be radiated, maybe it doesn't make much difference that I have IMRT.  They are going to radiate my prostate bed and in addition, the lower part of my bladder and my rectum...to be safe.  I hope I don't have any bad side effects.

I'm guessing the "loophole" that private Medicare insurers use to deny coverage, is I'm guessing Medicare calls proton therapy investigational/experimental, even though Medicare (along with some other private Medicare insurance companies) are lenient and will allow this therapy.  It's hard to find out for sure, since insured people calling in to ask, are kept away from the authorization people.  The insurance companies seem to want to wear people down, by making people like me send in letters of appeal...only to get replies that are not in plain English.

Hi John T:  What you say about using IMRT to work on a wide area sure sounds reasonable, since I don't have a small targeted area.  The IMRT place I went to for a consult last week specializes in prostate cases only.  And they are nearby my home.  If I would have been approved for proton therapy, I would have had to go 100 miles to the proton center.  So at least I don't have to travel so far now...lol.

Hi 142:  Thanks for your post also.  I'm curious, how did you find out that your insurance company will cover proton therapy for some therapies?  My insurance company wasn't so forthcoming.  They wanted the doctor to submit a code, then they would say if it would be covered.  If I would have known ahead of time that I would be denied for proton therapy, I would never have taken the time to travel to University of Penn hospital to try to get the therapy. 

That would be interesting to have people list which Medicare Advantage insurance companies will and will not cover proton therapy.  Then we all will know which insurance not to buy...lol.

Hi Water Guy:  Thanks for your reply also.  Looks like I won't get BCBS either...lol.  I'm thinking I will get regular Part A and Part B + supplimental + a drug plan for next year...although it will cost me a little more.  That should have me covered.  I use to think Medicare Advantage plans were better then having part A & B with a supplimental policy, but now I found out otherwise.  Insurance companies only "push" the Advantage plans much more then the supplimental insurance.

Thank you for your remark that you didn't remember anyone using protons for SRT.  That makes me feel better.  From what you and John say, it seems IMRT is the best way to go for SRT. 

Wow...thank you all for your replies.  It means a lot to me, and I'm sure to many others reading these posts.

Respectfully,

Bob

 

Post Edited (BobY777) : 4/15/2012 3:18:32 PM (GMT-6)

What makes you so certain Medicare will pay for proton when used as a salvage treatment? What is your PSA now??

Here is how it usually works..Medicare has a flat rate they will pay for salvage radiation therapy...X number of dollars and that's it...The provider agrees to accept this amount. or declines to provide the service...If the proton provider agrees to accept the offered amount, then you will get your proton treatment..If not, you won't.

Since proton treatment, when used to treat prostate cancer, has not been able to prove any advantage over photon treatment, the people who pay the bills are unlikely to ante up 2 or 3 times the amount photon providers are willing to accept...

It may be possible to find cases where Medicare has paid for proton treatment, but chances are that provider had to accept a MUCH lower fee from Medicare than the published "list price" for that treatment...

When it comes to $100,000 medical treatments, ALL KINDS of negotiation goes on backstage that you the patient are not privy too.....

Also, unless your post-surgery pathology report put you in the "high-risk" category, adjunct radiation treatment might not be warranted at this point....

I agree with the bulk of the other posters, and feel that IMRT would be a better salvage secondary treatment, rather than proton, even if money were not the problem. Salvage radiation is pretty effective, assuming that the remaining cancer is still in the prostate bed. The trouble there, is that they often have no way of telling that in advance.

I wish you good luck with whatever you end up with, and hopefully it will get the rest of the cancer present. Please keep us well posted of your own journey.

David in SC

I'm a G-9 too.. But after surgery, at 8 weeks, my PSA was still 0.9 That made my decision about further treatment very easy.. HT and RT combined...I searched around and found an aggressive radiation oncologist who had access to a Varian RapidArc LINAC. 72 gray in 40 fractions...My PSA has been undetectable for 16 months and my RO agreed to take me off the HT and see what happens...He thinks he got it. I hope he is right..My side-effects from the radiation? Zero..I had "Full Pelvic" radiation with a "boost" to the prostate bed at the end..Proton radiation is just not suited to large areas like "Full Pelvic" involves....It excels in treating small cancers in difficult locations...I would not get hung up on that...