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Anyone had radiation denied by insurance company?

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Posted 6/1/2015 6:33 PM (GMT 0)
Insurance company refused to authorize radiation. Will only cover surgery. Anyone ran into this?

Thanks
Tom
Posted 6/1/2015 6:40 PM (GMT 0)
Tom, I have not heard of this; perhaps someone will chime in who has experience. Nevertheless, it makes no sense. Suggest you call your insurance company immediately and try to get someone on the line who knows what they are doing.

Jim
Posted 6/1/2015 7:33 PM (GMT 0)
I've never heard of it either. Definitely appeal their decision. If that fails, perhaps you can negotiate for a lower cost radiation treatment like combo therapy (IMRT with a brachy boost) or SBRT.

- Allen
Posted 6/1/2015 7:55 PM (GMT 0)
My insurance (Humana) initially refused to cover my proton radiation treatment but I was successful on appeal in getting their decision reversed. Can't imagine an insurance company denying any of the less expensive radiation treatments. Definitely appeal. In most instances your radiation center will assist in preparing the appeal. That is just crazy.
Posted 6/1/2015 11:31 PM (GMT 0)
Let them know you will go ahead with the radiation and then sue them, and file a complaint with the state insurance commission, assuming the radiation is an accepted mainstream form. Make sure you get those comments to someone higher up,
Sometimes you just have to make some noise.
F'n ridiculous
Posted 6/1/2015 11:53 PM (GMT 0)
You should know that Surgery costs $30-$35K dollars. A 40 fraction radiation treatment can go $130K or more....

They both provide equal results....

Now you know where your insurance company is coming from..This is what you are fighting..It's always about the money...If YOU had to pay for this, out of YOUR pocket, what form of treatment would you choose then??

If you make enough noise your insurance company may relent but you will have to convince them radiation offers a substantial benefit..
Posted 6/2/2015 2:09 PM (GMT 0)
It is a few years back, but surgery was the route that was encouraged by my insurance as well.

They did outright deny proton radiation as experimental, and not proven to justify the huge cost difference at the time, nor the travel costs they would be expected to pay.

I was approved for IGRT, but was limited to the providers in my area.

I was approved for surgery, but was limited to the providers in my area.

I talk almost weekly to a care coordinator, and was on the phone with her just a few minutes ago. They still do not approve proton, and still would exclude travel if there were an in-network provider in the same general area.
Posted 6/2/2015 2:54 PM (GMT 0)

Fairwind said...
You should know that Surgery costs $30-$35K dollars. A 40 fraction radiation treatment can go $130K or more....

They both provide equal results....

Now you know where your insurance company is coming from..This is what you are fighting..It's always about the money...If YOU had to pay for this, out of YOUR pocket, what form of treatment would you choose then??

If you make enough noise your insurance company may relent but you will have to convince them radiation offers a substantial benefit..

The RO told me it's in my pelvis, just can't see it yet. So even if I go under the knife I will probably need radiation later anyway. Office said radiation is around $70k. I'm still working on this since radiation is covered in my contract.
Posted 6/2/2015 3:43 PM (GMT 0)
My surgery was $64K (I had excellent insurance so my out of pocket might have been $150 or so, can't remember).

My SRT was also about $64K. Same good insurance

Mel
Posted 6/2/2015 10:03 PM (GMT 0)
First off I would have your urologist contact the insurance company and explain why radiation is a better alternative for you. Looking at your statistics I would think radiation and hormone therapy might be better.

BTW, my robotic surgery cost approximately $70K and my out of pocket was only a few hundred.
Posted 6/2/2015 11:18 PM (GMT 0)
The list price of my proton treatment at UFPTI was $122,579, but Medicare knocked it down to $41,468. Medicare paid 80%, my Blue Cross supplement paid the remaining 20%. My travel, lodging, and meals were $6500, but all reimbursed from my HSA account.
Posted 6/3/2015 2:14 AM (GMT 0)
In the end BCBS paid most all of the $180,000 for all of my treatments.
Posted 6/4/2015 3:06 AM (GMT 0)
Sometimes the way the provider submits it can make a difference.

My first treatment year, I maxed out my yearly out of pocket, $5,000 in a day, the rest was covered. I chose to start in January for that reason. The same yearly is now $10,000 out of pocket.

As long as we keep the private insurers in the center of our $$$$$$$$healthcare system this is what we can expect. More cost pushed to the patient with higher deductibles and co-pays, more denials, with higher premiums. Somethings gotta give
Posted 6/5/2015 2:07 AM (GMT 0)
Never head of that happening for regular RT as being a primary PC treatment choice. Does not sound right or fair to me. Other's have been refused for Proton RT, as discussed, but that's another matter.

When I underwent first surgery, then later SRT, I was under Blue Cross of SC, and they never refused or hindered any of my treatment options.

Hope you get a better answer
Posted 6/5/2015 2:50 AM (GMT 0)
Sometimes simple things work..Have your RO write a letter to your insurance company explaining in detail why he feels radiation treatment is a better choice for you than surgery. If you can get your Urologist to support this position and sign the same letter, the insurance company has little choice other than covering the radiation treatments....
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