Insurance Driving Me Nuts!

Wow, Carol, sorry to hear you are having a tough time.

As far as oncologists, we have seen Dr Paschold once and really liked him. We have a second opinion appointment with Dr. Shen at Baptist.

If you still need the handicapped parking tag, see Charlie's primary care physician.

Suzanne,

The appeal should address the reason for denial and the specific plan provisions that cover the type of treatment you are seeking.  For example, if BCBS denied the PET because it was not "medically necessary", you should appeal their interpretation of medically necessary (it should be defined in your plan document).   Your physician's office may be able to help you there.

Didn't someone just post the findings of a study that showed PETs really can help in the diagnosis of his cancer?  That may be helpful to include aslo.

I would also get your employer involved (asssuming it is an employer sponsored plan).  Chances are you have a "self-insured" plan so the employer is actually the decision maker and the insurance company just an administrator in that case.

Let me know if I can help.  Keep fighting.  Good luck.

Bill

BCBS denied the PET because they say it is "experimental and investigational for cholangiocarcinoma".

Here is the post about the article on PET scans and their effect on treatment:

http://www.cholangiocarcinoma.org/punbb … hp?id=2179

Patty

Hi Jean,

Thanks for the info.  My doctor says he will help me only AFTER I make the appeal to the insurance company.  What am I, a doctor?  I don't have the medical knowledge to make a proper case.  This is so frustrating!  Plus, I'm getting information from a family friend/radiologist that the liver normally shows up very bright on PET, so it's really difficult to see anything.  But I read on this web site of people getting good information from a PET.  I'm very confused.  I don't want to give up but this is almost more than I can take.

Suzanne

Suzanne

I just can't imagine how frustrating this must be and I certainly don't understand why your doctor will only write a letter of medical necessity after you appeal it.  That makes absolutely no sense and only puts off the scan...it just seems wrong!  And it does seem unfair to put you in that position...as you said, you don't have the medical knowledge to make a proper case.  And how many people would!

I do know someone who works at a PET facility here in Seattle.  I will give her a call on Monday and see if she can put me in touch with the person who does their insurance authorizations.  I'll see if I can find out what would help obtain authorization, what wording to use, points that need to be made etc.  Hopefully I can find out something that might be useful.  I'll post on Monday and let you know what I learn.

I disagree with the information regarding liver lesions not showing up well on PET scans...I have seen PET scan images and a tumor is very easily seen.  I hate to disagree with a radiologist :-) but I just think he's wrong!

I am so much hoping for some good news for you.

Jean

Hi Suzanne

I was able to talk with one person today who was only marginally helpful and am going to try someone else tomorrow, so will post then.  We've had a big snow storm here in Seattle so many people haven't been able to get in.  Hoping a more helpful person will be there tomorrow!

Jean

Suzanne

I'm so sorry for my very slow reply.  I have had a very difficult week...my mother was brought to the hospital with chest pain, which turned out to be an aortic dissection.  She was in the CCU for awhile, but was discharged yesterday and is now home and doing quite well.  She was in a hospital 45 minutes from where I live, in good weather...then add the snow and ice and Christmas and work!   

I did want to let you know what I had found out about your insurance issue.  I was able to talk with three people in two PET departments.  They all said that while you can initiate the appeal, it is only the doctor who really has the power to work toward getting this approved.  I did learn that BCBS in Washington State is now approving all PET scans, regardless of diagnosis, but all have encountered problems with out of state BCBS plans.  The federal government/Medicare lists those diagnosis that they cover and when one fall outside these, the reason usually given for denial is that it is experimental/investigational for that diagnosis.  They all said that it can take a lot of persistence, but that the doctor most importantly, has to be persistent in the appeal...or maybe that the patient has to be persistent in making sure the doctor does what he/she needs to do!  They all suggested that you put in the appeal as soon as possible so that the doctor can do what is needed to help push it through e.g. faxing of all of the requested records.  One person suggested that you obtain the codes involved with this, putting it in your correspondence, and that might speed their processing.  That would consist of the diagnosis code (ICDA) and procedural code (CPT).  Another person suggested that you request a case manager from BCBS and that such a person can sometimes push through appeals/authorizations that might otherwise not have been approved, especially as they become familiar with your case.  Two people suggested that, once you have made the appeal, to obtain the name and phone number of their staff MD who reviews claims and have your physician call them directly.  It's called a peer to peer review.  They said that it is very commonly done and can be a great deal of help in obtaining approval.  They all said that your physician does need to be involved and is the only way for you to get this approved...they were adamant that you simply could not do this alone!  They were all quite surprised that you had been placed in this position and that your doctor was not taking more initiative in the matter.  I was just wondering if it would be helpful for you to contact the person who does the insurance authorizations for the PET facility that you would be using...I found all of these people really helpful and felt that they would certainly do all they could in helping obtain authorization.

There certainly doesn't seem to be any magic answers to this!  In essence, they all said that there wasn't anything that you could say that will really make a difference,  to go ahead and put the appeal in place, and then get your physician involved.

I hope you had a very good Christmas Suzanne.  Wishing you all the best in this new year!

Jean

Wow Jean!  What a lot  of great information!  I did in fact, yesterday, get in touch with my case manager at BCBS and she was able to guide me as to what to tell the doctor to say.  Isn't is silly that we, untrained professionals, have to tell the doctor how to navigate an appeal and what to say.  My case manager also said the appeal needs to be generated by the doctor.   I was able to get hold of my doctor's nurse practitioner and she was able to get the ball rolling with the doctor.  They will do the appeal for me.  I had no idea who to talk to or how to get this going.   You helped give me the back bone to go back to the doctor on this.  Thank you for all your help!  Happy New Year to you and your family!
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Hi Violarob - my understanding for the reason my doc wants to do a PET/CT is because I am looking at doing chemoembolization or radioembolization and the PET will help him see how much of my very large tumor is still viable, so the embolization will be more accurate.  There is a possibility some of my tumor has died due to the chemotherapy I'm on.  Thanks for you support......Happy new Year!