SBRT denied by insurance

We just got a patient portal message that Medical Mutual of Ohio denied the SBRT at the Cleveland Clinic. Not sure if they have appealed yet. Drs office is calling to discuss. Very frustrating! Steve is having a heck of a time making up his mind about treatment, but we really didn't want the insurance co making it for us!

I think Satan invented insurance companies. They typically relent on appeal, but what a pain! I think the appeal package should include the two links in my signature (btw - Dr Katz will be presenting 9 year results next month at ASTRO), the 5-yr consortium reports, the ASTRO model policy, the fact that Medicare approves it, and the cost vs IMRT. You might also want to include the study by Evans et al. that I recently published an article about, demonstrating lower patient-reports SEs compared to IMRT or LDR-BT.

Suz, depending on your level of anger over this you or Steve might want to call Satan directly about this to expedite the process. Their denial just does not make common sense, particularly given that this is a standard Medicare approved treatment.

My personal experience, as a Type A aggressive personality, is that a personal call to insurance over issues - small or large - usually yields the results I want. Anyway, just a thought...

Jim

Thx for that suggestion, Jim. We are already considering it. If Medical Mutual wants a fight, I will give them one (and smiling sweetly the whole time). Steve is much more diplomatic so between the two of us we might make some progress.

Allen - I got further details from Steve & I think they would only do 6 treatments, but doing 6 rather than 5 would allow them to code this as IMRT.

I don't think Steve can jump from my employer group plan to Medicare until Jan 1 and that is just too long to wait for treatment.

You should point out that the SBRT you desire, in 5 fractions, should cost a LOT less than a 40 fraction treatment of IGRT which is the "standard" treatment they are committed to pay for..The one thing they understand is money.....

I probably won't be able to get an answer on this from Medicare until tomorrow, but I wonder if we can transfer Steve into Medicare now? I'm sure there will be some kind of penalty since we are not in an "open enrollment" window. I have to confess I'm pretty ignorant about Medicare.

Suz,

I don't know your whole situation, but based upon DOB Steve should be eligible for Medicare immediately as he is already 65. There is no "open enrollment" for initial application. I have Medicare with a supplement (plan F) and all PC related charges have been covered 100%, no out of pocket so far.

Thx for all the advice, gentlemen.

We have decided to contact Medicare tomorrow to see what our options are there. Since Steve did not enroll in Part B when he was first eligible last year (DOB is 12/31/49) there may be a penalty or waiting period. We thought it was better to stay on an employer sponsored health plan, but then hindsight is always 20/20, isn't it?

Second order of business is getting more details on the 6 treatment plan. We want a comparison between how the radiation will be delivered in 6 treatments vs 5. I'm sure that discussion will open up even more questions. If we are not comfortable with the 6 treatment plan, we will start the appeal process and calls to the ins co to get SBRT approved. Just a lot of added stress to a situation that is already stressful enough.

Thanks again for all the support!

Suz

Since he was on an employer sponsored plan there is no Part B or D penalty. You will probably have to show Medicare proof of his coverage at some point.

Medicare Supplement insurance is accepted by all providers that accept Medicare, so there aren't "networks" in the same sense as your employer sponsored plan. All you have to do is first confirm that the provider accepts Medicare and then you are good to go.

just FYI, the way my medicare supplement works - is if medicare pays, they pay the balance. If medicare doesn't pay, they pay nothing.

And, although the doctor/hospital/lab bills for my sinus surgery were much higher than what medicare and supplemental paid, all bills come back I owe zero balance.

Signing up for part D in October when open enrollment comes around

Plan F (not the high deductible one) is considered the most comprehensive (and expensive) plan.

we have plan F.

Have a Blue Cross/Blue Shield card for coverage. Mainly because BC/BS is the predominate carrier in my area.

Has been wonderful.


160 month for me, 152 for my wife.

suzhtz said...
Quick update. Wheels are in motion to get Steve off my ins plan and on to Medicare. Possibly as early as Oct 1, but by Nov 1 for sure. Better news than we thought as Jan 1 seemed a long time to wait.

The upside - With Medicare comes a greatly expanded "network". I think Steve is pretty comfortable with the Cleveland Clinic but we've also had some email exchanges with Dr Chris King when deciding between SBRT and HDR brachy. Not trying to muddy the waters -- just thinking ahead.

Suz - Karen and I are looking forward to meeting yu adn Steve in Rochester next week.

Dr. King did my SBRT and Dr Scholz's office in Marina del Rey CA oversaw my Provenge. both 100 % paid for by Medicare and AARP/United Health Care Medicare supplement Plan F.

Though I live in west central FL and they are each in CA, no issues.