Insurance vent - SBRT

Some who have been around for a while may recall that we had a heck of a time getting Steve approved for SBRT at the Cleveland Clinic last year. After we were denied coverage for this TX, our RO appealed and had to plead Steve’s case with a general surgeon who did not know a prostate from a pimple and who upheld the denial based on SBRT being “experimental”. (Our RO got around this by delivering 6 SBRT treatments rather than the usual 5 so he could attach an IMRT procedure code to the treatment billing.)

I’ve been contacted several times by a couple who got our info thru this forum (and Tall Allen, I believe). They were considering SBRT at Cleveland Clinic but ultimately decided on Sloan Kettering. Got an email from them on Monday and the SBRT was denied! The DH has been on Lupron for several months and they were just getting ready for fiducial placement. I am hoping that their RO has better luck with their insurance company than we did.

Last night we were at a local Prostate Support group and met two other men who also had their insurance companies recently deny SBRT, one a G7 like Steve, and the other a G9. I’m venting here and don’t want this to turn into a rant, but WTH??? Is it standard operating procedure for insurance companies to routinely deny SBRT? I know how much stress the denial added to an already VERY stressful situation for us and I am just seething over what these three men and their families are now dealing with.

Suz

It bewilders me. A therapy that's been used in the US since 2003, and has a 9-year report (on a much bigger population) vs 10 year max for IMRT, and there is endorsement from ASTRO, and there is a registry, and it is cheaper and has an excellent safety record - why would they not be thrilled to cover it? I have found that they will often approve it on appeal. Fortunately, Medicare covers it.

I recently saw this list of states denying SBRT...still pretty substantial:

States in which men on Wellpoint/Anthem plans are denied coverage for the SBRT option include (alphabetically): California, Colorado, Connecticut, Georgia, Indiana, Kentucky, Maine, Missouri, Nevada, New Hampshire, New York, Ohio, Virginia, Wisconsin. There are also a few regional Blue Cross/Blue Shield states still denying coverage. These include Illinois, Montana, New Mexico, Oklahoma, Texas.

Let me repeat a story I mentioned here a year or two ago. When I got hired on my last job, we of course had a meeting for all new employees to discuss benefits. Well one big sales pitch for our insurance was this: If you need a specialized treatment of any kind that can ONLY be done at a specified “Center of Excellence,” and is medically necessary, then the insurance will cover the procedure and reimburse you and a caregiver for transportation and lodging. I remember laughing at that. What crap! Who would ever be in THAT situation; some procedure that can ONLY be done at some top place.

Fast forward to 2014. Dr. Lam suggested I get the C11 Choline scan, which can ONLY be done at Mayo. I somehow remembered that clause and brought it up with my insurance company. I can’t remember the specifics, but they were clearly SHOCKED that someone would actually use that clause (a lot of hemming/hawing). They made me go through plenty of hoops. Dr. Lam had to write a letter as to why I needed that. It took awhile, but it got approved. So, my final $15000+ medical bill (included consultations, blood tests, and an MRI) got covered (my cost was a few hundred bucks as I remember). The best thing: they reimbursed our plane fairs and hotel costs. I never did check if our food costs were covered. Darn!

I think that's the only time I ever thought of dealing with the insurance company as a VICTORY.

Unfortunately, I no longer have that cadillac plan. I am slated to repeat the scans at Mayo in the very near future. No victory this time, but hopefully my MediCare Advantage plan will cover most of it.

Mel

Redwing:

I think you are erring just a tad on the cynical side, but we all seem to have insurance stories -- most of them not good these days. So, yeah, you get a little jaded.

Frankly, I am for providing all Americans with health care. It is a disgrace that we don't. But the main issue is skyrocketing medical costs, with truly no end in sight.

We applaud all these new drugs like Xtandi, etc. Yet, in our joy we look at the costs. It is nice when our great insurance covers it. Nice for us. Not nice for the poor guy who had good insurance and got laid off and now has nothing. We talk about getting frequent PSA tests, scans, etc. for many of us. Advanced PC can bankrupt any of us, if insurance is lacking...or, more likely, we just go without.

Incidentally, I would not object to insurance only covering major issues. Why should every doctor visit be covered. I see nothing wrong with being covered for major events, tests, drugs, etc. but skipping other things. Maybe something a little better (or not) than catastrophic care. Maybe tied to income or net worth?


None of us have the answers, but there is such a humungous difference in quality of care and insurances.

Those of us who have insurance are VERY fortunate.

This is probably bordering on a political post, but since you mentioned ObamaCare...

(Then again, the moderators have had enough of a vacation. It's time they started earning those big bucks!)

Mel

Mel -

Oh, I'm overly cynical to be sure. Gets worse all the time too, because frankly it becomes reality all too often. You can't even stay ahead of the developments... life seems like it's being written by The Onion!

Not meaning to be "political", I do that in too many other forums. But here, on this topic, it does seem like cost will drive everything no matter what the support structure is. And the governmental meddling in the health insurance market creates massive distortions, leading to us having to figure out how we'll get things like SBRT covered for example.

The idea of paying the little stuff yourself, and insurance covering the big ticket items, is really what HSA-style insurance is for. They even tax-shelter the HSA account to help you pay for health care items.

Had posted before that I was warned that I would be delayed for SBRT approval, and might not even got approval, even with my doctor petitioning for it. Was a major reason I opted for HDR Brachy, rather than delaying treatment.

Don't think it's a question of cost. My HDR (100% reimbursed) probably didn't cost that much less than SBRT. And If I had wanted surgery that would've been covered, and would've been more expensive than SBRT.

Inertia, conservatism of the health insurance providers, trying to protect the interests of those presently performing procedures?

Some insurance companies have 'evolved' into slow moving bureaucracies. Fortunately, my BC/BS didn't give me any hassle. And I was a Gleason 9!