Topic: SIRT - Y90

Hello,

My father recently had the SIRT - Y90 treatment, and it seems to really be working well.  The vessels that feed the tumors in his liver are shrinking, therefore decreasing the chances of the tumors getting any larger.

I have one question for anyone who has gone through this same treatment:

Was this treatment covered by your insurance company?

Here's the problem.  My dad has Blue Cross.  They initially denied coverage of this treatment stating it was "too new" of a treatment and that there weren't enough successful cases to prove it is worth is basically.

The doctors told my dad to go ahead with the treatment, pay for it, then they would send a letter to the isurance company appealing the denial in order to get my dad reimbursed.  My dad paid close to $100,000 out of his pocket with the expectation of reimbursement.

Yesterday, we received the second denial letter.  This letter now states that we will have to submit an appeal to the Insurance Commission.  It also states that he is only eligible to even be considered to an appeal if he would have died without this treatment.

I am desperately trying to research or locate any cases where Blue Cross, or any other insurance company, has covered this treatment. 

If anyone can help, or direct me to somewhere that can, I would be ever so grateful!!!  It's hard enough to deal with the illness, having to fight the insurace company makes the struggle twice as hard.

Thank you in advance,
Nicole

Re: SIRT - Y90

Just do a search, there are several people who have had this treatment. 

Keep on pushing with your insurance company, we had to play hard ball several times.   You may also find out if Blue Cross has an advocacy service.  Where they provide an advocate who works with the insurance company in your Dad's behalf.

Stacie

Re: SIRT - Y90

Also, be sure to have the Dr's who did the treatment write letters to your insurance company letting them know how important the treatment was and that it is working successfully.

Stacie

4 (edited by marions Sat, 17 Nov 2007 22:43:24)

Re: SIRT - Y90

Blue Cross did not provide us with an advocat in 2006 they did however, allow us to have a case worker due to the fact, that it was CC. 
It proved itself to be of tremendous help, as plenty times the need arose for a quick response from the insurer.  The case worker went so far as to keep me posted whenever she would not be available.
Unfortunately, once a denial had been entered in to the computer system, the case worker had no authority to implore for any changes to be made.
Still, it is always beneficial to have someone from the inside working with you.
Wishing you the best of luck
Marions

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: SIRT - Y90

I wish I could confidently tell you who paid for what for the SIRS Spheres treatment (Y90) treatment I had last November.  Before I go into the payment, I should mention that my latest scan last week showed that the tumors had not gotten any larger since the Y90 treatment in November 2006.

As for the payments, I am on Medicare as the Primary and have Dean Health Insurance (Wisconsin company) for the secondary insurance.  I had the preparation for the procedure in Oct. 2006 at a cost of about $10,000 and the actual treatment in Nov. -- the initial cost of over $64,000.  There might be other costs, but I didn't see any after quick scan of my very thick insurance records.  Medicare turned down many costs for the October treatment, but I think, after appeals from the doctors, they paid most of the costs.  I'm not sure how much Medicare paid and how much Dean Insurance paid.  To add to my confusion, the first bill for the November procedure was $60,440 of which Medicare paid $21,731 in Feb.  I have not received any bills on the procedure so far, so I assume, maybe Dean Insurance paid the rest, but I don't know for sure.  However by November it seems I should have hears one way or another.  Dean has previously paid for chemo and treatments which Medicare has turned down.

Related also is that in October of each year I have the option to choose a different secondary insurance.  I was considering changing from Dean Insurance, which requires referrals, to a Wis. Physicians Service Insurance which was formerly Blue Cross.  This insurance did not require a referral.  Fortunately I did not switch carriers and later was told WPS only covered textra costs of  the treatments/chemos approved by Medicare.

This whole post is to indicate that I think the Dean Insurance did cover costs not covered by Medicare for the Y-90 treatment -- but it is all very confusing as you have found out.  Even my oncologist has trouble interpreting Medicare for his mother.

Best of luck with your insurance, and more importantly with your father's treatment for CC.

Re: SIRT - Y90

Thank you all so much for the helpful information.  We have sent in our appeal to the Board of Insurance and we are waiting to hear if they will approve an Independent Medical Review.  Thanks again!  Every little bit of information is helpful and greatly appreciated!

Nicole

7 (edited by Caruso149caruso Sun, 06 Jan 2008 15:08:14)

Re: SIRT - Y90

My husband had the spheres treatment in July 2007 after having been diagnosed in December 2006. He has Aetna insurance. One of the criteria for them to pay was that he had to have a prognosis of one year to live or less. The cost is $100,000  dollars. They approved the treatment. Since then there has been no new growth of the tumor which was six inches across. He takes a chemo pill. No IV chemo. He does get Avastin IV every three weeks at Duke University Medical Center. Aetna initially did not want to pay for it. He works for a big company that donates lots of money to medical centers and research. Unfortunately a lot of people don't have access to this treatment because of the cost and that is unfair. At the present time he is stable . He has no pain. His main problem seems to be constipation. Occasionally his voice gets hoarse but he is on the phone a lot at work. He still goes to work and occasionally travels. He has had one episode of ascites and was hospitalized four days while being treated. That was in September 2007. There have been no further episodes. Good luck to all. Annie

Re: SIRT - Y90

Caruso149caruso wrote:

My husband had the spheres treatment in July 2007 after having been diagnosed in December 2006. He has Aetna insurance. One of the criteria for them to pay was that he had to have a prognosis of one year to live or less. The cost is $100,000  dollars. They approved the treatment. Since then there has been no new growth of the tumor which was six inches across. He takes a chemo pill. No IV chemo. He does get Avastin IV every three weeks at Duke University Medical Center. Aetna initially did not want to pay for it. He works for a big company that donates lots of money to medical centers and research. Unfortunately a lot of people don't have access to this treatment because of the cost and that is unfair. At the present time he is stable . He has no pain. His main problem seems to be constipation. Occasionally his voice gets hoarse but he is on the phone a lot at work. He still goes to work and occasionally travels. He has had one episode of ascites and was hospitalized four days while being treated. That was in September 2007. There have been no further episodes. Good luck to all. Annie

Re: SIRT - Y90

Annie,
I know it's been a while since your post, but I just came across it while looking up information about ascites. My father had SIR-Spheres in early September and now suddenly has ascites as well. When your father was hospitalized for four days, how did they treat him?

Re: SIRT - Y90

Have you tried contacting the company which developed the SIRT-Y90 microspheres? I think they have a new patient advocacy web site. You might be able to network with some folks there. Best of luck!

Violarob in Texas

Re: SIRT - Y90

Thanks, I will definitely try it.

Re: SIRT - Y90

My husband had the y90 treatment in Feb 2011.  It i now Mar 2011 and he is still having side affects.  He is sick to his stomach and has like a cold.  has anyone had these side effects and how long did they last?

Re: SIRT - Y90

Hello Arndt and welcome to our site.    SIRT-Y90 has been discussed on out site.  Until others have a chance to respond to your questions you might want to use the google search function on top, right. Simply enter SIRT-Y90 and numerous discussions will appear.   Let us know if you need help.  I am wondering, does your husband also have regular scans and blood tests?  And, if so is everything within the normal range?   I am glad that you have found us and I am looking forward to many more of your posting. 
All my best wishes,
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER

Re: SIRT - Y90

Hi Arndt,  I have been a lurker on this site for several years as several friends have had cholangiocarcinoma and are members here.  I have had SIR-spheres would love to help answer any questions you might have.  You can also find information at www.beatlivertumors.org about SIRT. 

Hope to hear from you soon. Suzanne