What does a 50% survivability in 5 years standard mean and who can tell?

I posted this issue or question in my first post and I will post it again but first some details...

My medical insurance company is refusing to pay for chemotherapy treatment because it is against its policy of "not paying for cancer cases with poor prognosis or those cases under the "50% survivability in 5 years standard..." First my doctor told them that he could not be certain of my prognosis because it would depend on individual patient's response to chemotherapy and in fact told the insurance company that I have been responding very well so far to several chemotherapy sessions with taxotere followed by peglasta. He also told the insurance company that giving such number would be purely arbitrary.

But the insurance company keeps insisting on getting what it terms as a "simple and straight forward answer.."

Is it normal practice for doctors to tell insurance companies how long their patience will survive 50% in 5 years of the treatment? Who can accurately predict how long one lives?

Is the "standard" quoted by the insurance company an accepted "standard" or it's own creation?

God, the system here can be so disgusting. My mother might not have more than 6 months according to what I've been reading online but she is getting everything for free in Italy including radiation from Wednesday on and then chemo.

Bermin, i'm truly sorry.

Thank you Bill. I believe when you read my next posting. I believe that the doctor did what you are suggesting in the best way from the experience he has had with his other patients.


Doctor’s initial response to the insurance company…..

“…The patient's PSA levels had been rising up quickly from 289.12 on December 24, 2012 to 407.14 on January 15, 2013 and 672.48 on January 29, 2013. I decided to start him on Chemotheraphy with Taxotere (Docetaxel)/Admission and Peglasta (pegfilgrastim) support. He appear to respond nicely and the PSA is reduced to 452.02 only 1 week after the chemotheraphy delivered. I plan to continue him on this regimen (given every 3 weeks) for now and monitor his PSA…”

The insurance company pressed on and my doctor responded, thus:

"…His 5-yr survival prognosis is uncertain, depending on how he responds to the chemo therapy. We have been giving him Docetaxel/Prednisolone for 3 cycles with great response with PSA from 672.48 --> 111.740. 5-yr survival prognosis is just an arbitrary number. It would be sad if you will not extend his coverage because of the statistical number that might not be relevant to him who is doing quite well on his cancer treatment…”

My note: I have had 5 chemotherapy sessions between January 29, 2014 and April 23, 2013. My PSA went from 672.48 to 75.39.

I think anyone with common sense will not be totally wrong to conclude that the patient described herein has a better than 50% chance of surviving for the next 5 years.

Bermin

Thank you Special Lady. I neglected to mention in my posting that during the chemotherapy sessions, I only managed to loose some hair on the head and a 5-day diahrrea run and a one day muscle spasm? around the chest. I consider myself very lucky to be responding well to the treatment. My knuckles are swollen from "Knocking on wood" for a better future. Thanks.

Bermin,
We spoke before. When I did not know all your details I referred you to the Sloan Kettering nomogram site where patients can enter their numbers and primary treatment and SK gives the expected 50% survivability data at 1, 2, 5, ar 5 years 10 years etc. Your situation was so much ore complicated it did not apply.

How is your health otherwise? Are you fit for your age? Are you overweight? History of heart trouble? Smoke?
I am asking for a reason. If your other numbers are good you can run them through another life expectancy site like realage.com (I think. Search for predicted life expectancy or How long will I live? You will find reputable sites). That will give the numbers for someone with no cancer but with your stats.
You can then supply that to the insurance company and say "According to the (e.g.)US Dept of Labor and American Actuarial Data Collection Organization you have a 50% survivability of (e.g.) 20 years if you can eliminate cancer."

You can then give that information to the doctor for his appeal process. Write a sample letter yourself with all the pertinent information and references and give it to your doc. That will help him when he writes the appeal letter.

Obviously, if you are a smoker, are grossly overweight, have diabetes, and are over 80, that approach will not work. Even without PCa your 50% survivability might be less than 5 years.

I wish you well.
Jeff

Edit by me. It has been many years since I went to realage.com. I just checked they still exists but they now tell you your age not your life expectancy. (Less morbid?) That might still be useful.
Search around. I am sure you will find another site.
I just found University of Pennsylvania's calculator http://gosset.wharton.upenn.edu/mortality/perl/CalcForm.html .

I just ran my numbers through UPenn and it gives life expectancy in quartiles. It says my 50% is XX years. I intend to make them count.

Post Edited (Worried Guy) : 5/14/2013 7:05:05 AM (GMT-6)

Thank you very much Jeff. I will advise what I find.

Time to pull out all the stops. As Tony said get to the Insurance Commissioner. Get with your employer, the actual policyholder for help. Call your congressman and find the best threee and most influential consumer advocates in your area and tell them the story. Nothing like being on TV. What you are experienceing is exactly what is done in England. Tthis is an example of the so called "death panels" that Sara Palin referred that take into account the cost of a treatment and the likely span of life to detrermine whether treatment is warranted. Of course many people said nothong to worry about....but for you it appears very real.

Thank you Tony. The Plan is government run where employer-employee pitch into it. There is an appeal process but I am not there yet. I am gathering information for now for the day when I will appeal.

Sorry if my comments come under you ax. This insurance is run by the goverment through a Board. Members are government employees, non-government employees, their dependents and agencies.