Insurance Cos increasingly resistant to scans

[boxhill]

Last year, when my oncologist and I first discussed taking a look at my liver with an MRI--since surgery found a 5mm met that didn't show on CT--he told me that insurance companies were becoming increasingly resistant to approving scans, and we'd have to "make a case for it." Long story short, my pre-, during-, and post-chemo CTs were all NED. But Cigna agreed to an MRI, 12/20/18, which revealed a new 5mm met and two enlarged lymph nodes, which led to starting Keytruda immediately.

So in May, he planned to do another MRI to see what was up with those masses. (No scans since 12/20/18) Anthem BC/BS refused, citing their policy that I had to have a CT scan unless I was allergic to the dye or had some other medical problem. And they took their sweet time about it, I might add. Doc tells me that the "peer-to-peer" consultation consists of him waiting on hold for 10-15 minutes, then having the "physician" simply read the policy to him, and repeat after he explains WHY a CT scan is kind of pointless for me.

Upshot is that I am having a triphasic CT on Wednesday, which apparently shows somewhat more in the liver than the regular kind. But of course, if it shows nothing, we will not be certain whether that means the met is actually gone. *Maybe* we can tell if the nodes have shrunk.

On the other hand, it could show progression. But that's another problem.

So if it looks clear, do we then request an MRI? This is nuts. The insurance co authorized something like 24 infusions of Keytruda, at a cost of probably around $240K, but they will make me potentially have 2 scans instead of one and be exposed to more radiation just because in some cases this policy saves a couple thousand dollars. An MRI will show whether the drug they are prepared to pay over $200K for is actually working.

Last week he told me that companies have been balking at use of approved drugs for their approved purpose, not even off-label, and the latest agony is that they are refusing to authorize lab tests. All for cancer patients.

[Deb m]

Dam insurance companies. You can't live without them, but you can barely live with them!

deb

[debsta]

We also have Anthem BCBS (GA) and are getting far too experienced with the appeal process! Sometimes I feel like my husband is the cancer warrior and I am the insurance warrior.

Do you have an ACA plan or an employee group plan?

If you have an employee group plan, I would strongly recommend asking your company's HR Benefits Rep (in our case it is the HR Director) to reach out to their insurance broker and put the pressure on for coverage of denied services. This has worked for us several times when peer to peer review appeals were denied. We didn't need to disclose any personal information other than providing her with the general diagnosis (which she already knew) and the EOB denying the service.

Good luck.

Deborah

[Beckster]

I am a retired educator and have NJ Horizon Blue Cross, which is an excellent insurance. However, just recently, they denied my 6 month CT scan. Their reasoning was that according to National guidelines, Stage II and III should only receive yearly scans. My doctor had to have a peer to peer conference and fight for the scan. Luckily, he got it approved, but it will happen again in December.

Beckster

[boxhill]

Our plan is through my husband's employer. I'll pass on the HR/insurance broker angle to my H.

He talked to the advocate yesterday--she's apparently an RN--and she said that it is SOP to require a CT before an MRI, and that they should approve an MRI now, assuming that the radiologist and my oncologist state that the CT was unable to provide a sufficiently clear view of my liver. I would hope that if they deny the MRI now, the advocate would step in after a failed peer-to-peer. We can always follow the appeal process in any case.

I noticed last year that the post-chemo radiologist's report contained some new language to the effect that there was no activity *that could be determined by CT*. He and my onc were making the case for the MRI.

Meanwhile I'm hoping to drive over and pick up the report this afternoon. Keeping my fingers crossed for the efficacy of Keytruda.

[rp1954]

Dam insurance companies. You can't live without them, but you can barely live with them!

Actually some can theoretically live without them and prosper, we did totally without them for years 1, 6, 7, 8. Year 1 because claims and fights would slow us down, sap energy and frazzle nerves. You would laugh at our low insurance benefits yrs 2 - 5.5 (my wife aged out after 65). Many might envy the lifestyle aspects of my wife by not fighting the medical and insurance systems, not suffering from the treatments so, not over paying generally, not paying much for time wasting nonperformers and parasites; mostly getting what we wanted at home or a better-than-US-average hospital experience. Her yearly medical and cancer costs have never equaled the published ACA premium rates for her in the US either.

So no ACA/US insurance premium, no US insurance drug and medical deductibles, no formulary restrictions, and no US insurance declines, we're at least $ $$$,$$$,$$$ ahead right now. Both of us probably would have died, me apoplexy or heart, her either cancer or apoplexy, with the "normal" US bs.

We achieved enough self sufficiency the first month(s) to avoid lock-in to more expensive, less effective answers and providers in 2010. And there's the rub, taking effective actions near the start, and to be willing and able to be, or become, more independent and self sufficient without too many mistakes (hopefully fewer than with insurance "guidance"), and probably outside the US part of the time. Also the newest, sometimes insurance participating, ultra expensive medicines can be somewhat more enticing in 2019 than 2010, dependent on your particular cancer biology (my wife still wouldn't benefit enough with the most commonly fatal CRC features). However, my inspiration for independence is an older friend and her sister in the US, cancer survivors from ~25 years ago.

To me, US medical costs, insurance rates and the practices of both have become unsustainable. But I don't particularly want US/European style single payer answers either - most might be too low benefit/high cost and effort for us (obstruction, refusal and interference are big negatives).

[boxhill]

BTW, **after** the triphasic CT was performed, I received a letter from Anthem informing me that AIM Specialty Health has approved a procedure for me which is described as "CT ABD & PELVIS W/O CONTRAST."

I don't know about you, but to me this looks like they approved a CT without contrast, which is obviously not what I had. I'm hoping that this is a case where the code is correct but the verbiage leaves something to be desired, because naturally this approval includes a warning that that doesn't mean that Anthem will actually PAY for it.

Ya gotta love it. Right?