Insurance denial advice.

[KWT]

So I'm fighting with ins. Over RFA on a couple lung mets, they state that it is experimental/ investigational. So I'm gathering up studies and wondering if this document helps or hurts my case? Thanks

http://www.fda.gov/MedicalDevices/Safet ... 061985.htm

[peanut_8]

KT, these 2 paragraphs seem like this article would not help your case. Hope you can find better ones.

FDA has not cleared any RF ablation devices for the specific treatment indication of partial or complete ablation of lung tumors. Manufacturers of RF ablation devices cannot legally market them for this treatment indication until they have presented to FDA clinical data sufficient to establish safety and effectiveness for this purpose. Manufacturers have asked that they be allowed to provide training for clinicians related to this ablation of pulmonary tumor use. FDA cannot permit manufacturer-sponsored training for a specific indication that has not been cleared. This does not apply to training that may be available from other sources.

Public health concerns
FDA has received reports of death and serious injuries associated with the use of RF ablation devices in treatment of lung tumors. Since we have not reviewed any pre-market clinical data in support of this specific treatment use, we do not know the actual adverse event rate. Therefore, we cannot say if these deaths or injuries are occurring more frequently than with other forms of treatment for lung tumors. These adverse events could be related to a number of factors, including patient selection and management, technical use of the RF device, post procedural treatments, and management of complications.

[KWT]

That's what I thought also, but there is a risk of death anytime they do surgery. I have a lot of stuff I sent to them. I'm certain at this level of appeal their not even reading this stuff just making sure the follow their guidelines and making decisions that are favorable to the shareholders.

[peanut_8]

I think your probably right about not bothering to read the stuff, and absolutely right about making money. It's actually shocking how much money they make. My onc told me how much BCBS makes a quarter. Of course I don't remember the exact amount, but I was surprised it was so much.
peanut

[lpas]

Who's your carrier, Kenny? Some of the bigger names like BC/BS will often maintain public documentation justifying their position (with cites) on what's considered experimental and what isn't. If you can get a look at it, you can see what studies they're relying on and how old they are. If they haven't reviewed/updated their position in a while or the studies are old and you can find newer ones, that would help bolster your case.

[bitchslapped]

It doesn't help IMO.

Have you seen this?
http://www.ncbi.nlm.nih.gov/pubmed/23026111

Also this shows just what PUBMED is for Pete's sake - government website:

http://www.ncbi.nlm.nih.gov/pubmedhealth/about/

If Medicare doesn't cover something, then a free forall for ins. If it's not FDA approved for a particular application, then obviously problematic. I don't get it. RFA has been around a long time.

Good Luck
BS

[Delinda2]

So sorry you have to fight the insurance battle too. (Makes my puny little problem seem ridiculous. Thanks for the reality check.) Cancer sucks, and then it sucks some more. And just when you think that's enough, it REALLY sucks. Carry on dude.

[KWT]

Thanks guy's, and yes BSlapped I did find those, thanks. I would imagine if this goes to an outside appeal things may be looked at closely but not at this level. It just seems like the make it hard and he'll go away game. Hell, I don't even know if I will go through with tha ablation at this point with Cea dilemma and potential trial. But it is an option to knock out the 2cm guy before he starts causing problems.

Heck Dee, I hope you don't have a problem at all, I have some pain in the same place you describe but it feels like a muscle strain that's hangin in there. It is right where the ileo work was done. I figure I had no pain at dx and that was part of the problem

[cathy123]

Hopefully if you make it hard on them they will be the ones to give in. So sorry - that sucks!

[vilca11]

Kenny, the only thing that can help if you do decide to go thru the percutaneous RFA, is the Insurance Commissioner of your State. Medicare does not state that the service is non-covered, it just gave authorization to Local Contractors of Medicare (MACs) to decide on coverage themselves...

Prepare documents ( the policies that do cover RFA on lungs) and send to IC with request that they allow the coverage that your payor is refusing to give.... FDA document is very old, 2008, and they do speak about general approval...so, in general it is approved for treating lung tumors, therefore there is no issue... the language is vague later in the document, but that is not important (do not show them that document), show instead more of those: (make sure you fit into criteria of coverage - less than 3cm, etc)

Examples of payor policies covering RFA lungs:

BCBS of Rhode Island Lung Ablation policy from 2014 (very good and detailed rationale in the form of studies listed)(() https://www.bcbsri.com/sites/default/fi ... alV1.1.pdf

Covidien: http://www.covidien.com/imageServer.asp ... cation/pdf

HealthNet (Federal payor!!! for Veterans)https://www.healthnet.com/static/general/unprotected/pdfs/national/policies/Radiofrequency_Ablation_of_Lung_Tumors_Nov_10.pdf -

Is not it terrible that cancer patients have to deal with this S#%#T... Vilca add what others cited from PubMed if you go thru IC

[skypup]

Dang, Kenny, if it's not one thing it's another. Be the squeaky wheel!

[KWT]

Thanks very much Vilca, I know you're dealing with your own issues. Thanks for your thoughts.

[KWT]

Dang, Kenny, if it's not one thing it's another. Be the squeaky wheel!

I'm trying but this is ridiculous. I'm going to make a cardboard sign and sit outside the insurance company's door. it's only 20 minutes from me.

[gator.girl]

I can't offer much help but heard this before -
request to know who is evaluating your case at the insurance company - sometimes the docs who are reviewing these appeals don't even have a clue about the disease they are supposed to make decisions on…

my 2 cents...

[KWT]

Yeah GG, the dr reviewing the case was an internist / nephrologist most likely not to up on RFA of the lungs. What kind of a dr sells out to work for an insurance company? $$$$$


You wouldn't want a podiatrist second guessing your gynecologist