The Colon Club

Got a letter from our insurance company saying that they will not pay for the genomic testing....has anyone written an appeal before? That’s where we’re headed...

Very strange decision at Stage IV - can your oncologist perhaps schedule a “peer-to-peer” call with the insurer’s medicos to explain why genomic testing is necessary to inform the chemo regime? (I’m sure they’d rather not pay for drugs that won’t work...)

Cheers
Rob

My testing was denied by my insurance company as well and my oncologist appealed. They actually denied the appeal and the hospital paid. He said MGH has a “fund” for such situations. I would ask if they can appeal and what, if any, other options exist for payment.

Many Oncology sections have Nurse advocates that can help mitigate such insurance road blocks. Keep asking, appealing and getting professional referrals. Nothing is easy in this fight, but so many treatment options can opened-up for patients with special genetic profiles. Genetic testing is the key to better understanding of what you and your family are confronting. Maybe a major cancer center in your area will have a better approach, keep calling and asking until you get the answers that satisfy you. Best wishes!
WS

My coworker with lung cancer has had it a few times as he's had mutations. He goes to Dana Farber. Our insurance doesn't cover it either but I suspect that his oncologist at DFCI convinced the insurance company to cover it.

I asked my oncologist at my local hospital to do it and he ignored me (laughed it off). I think that he was surprised when I got it without his help.

Amarie123 wrote:My testing was denied by my insurance company as well and my oncologist appealed. They actually denied the appeal and the hospital paid. He said MGH has a “fund” for such situations. I would ask if they can appeal and what, if any, other options exist for payment.

MGH does the testing on-site - they don't send it out. So they may have more flexibility. They did mine for free too.

My insurer denied the Foundation1 Testing that my oncologist ordered, stating that it was still experimental. My oncologist appealed (it was denied) and I appealed with lots of research and my appeal was likewise denied. However, my insurance DID approve off-label treatment with Keytruda even though I was MSS, so I cannot complain.

Cynthia

Jack&KatiesMommy wrote:My insurer denied the Foundation1 Testing that my oncologist ordered, stating that it was still experimental. My oncologist appealed (it was denied) and I appealed with lots of research and my appeal was likewise denied. However, my insurance DID approve off-label treatment with Keytruda even though I was MSS, so I cannot complain.

Cynthia

I was looking at two of the papers on the new BRAF treatment and was wondering how insurance companies don't do Genomic testing given that the choice of chemo used can affect the cancer.

Thank you all for sharing your experiences and well wishes! My husband called his oncologist yesterday, and his doc is calling to appeal. The testing is being done at Yale, so I'm not sure how they might handle a situation like this, but we will ask at our appointment next week. Yes, we will keep pushing until my husband gets the care that he needs and deserves . . . it was kind of a blow, but just another battle along the way. We're headed to MSK tomorrow, so stay tuned . . . I hope to have some promising options to share
jep

NHMike wrote:

Amarie123 wrote:My testing was denied by my insurance company as well and my oncologist appealed. They actually denied the appeal and the hospital paid. He said MGH has a “fund” for such situations. I would ask if they can appeal and what, if any, other options exist for payment.

MGH does the testing on-site - they don't send it out. So they may have more flexibility. They did mine for free too.

I did see results that were processed at MGH (which identified the KRAS mutation) but there was also Guardant360 genomic testing done which took about 3 weeks to come back. My onc warned me that the claim would likely be denied but said that they would handle it on their end if needed.

Either way, a larger hospital should have an obudsman (I think that’s what it’s called) to help advocate with insurance if the oncologist and their team don’t do this. It doesn’t make any sense for insurance to deny these claims.

Amarie123 wrote:

NHMike wrote:

Amarie123 wrote:My testing was denied by my insurance company as well and my oncologist appealed. They actually denied the appeal and the hospital paid. He said MGH has a “fund” for such situations. I would ask if they can appeal and what, if any, other options exist for payment.

MGH does the testing on-site - they don't send it out. So they may have more flexibility. They did mine for free too.

I did see results that were processed at MGH (which identified the KRAS mutation) but there was also Guardant360 genomic testing done which took about 3 weeks to come back. My onc warned me that the claim would likely be denied but said that they would handle it on their end if needed.

Either way, a larger hospital should have an obudsman (I think that’s what it’s called) to help advocate with insurance if the oncologist and their team don’t do this. It doesn’t make any sense for insurance to deny these claims.

The Guardant360 testing appears to be genetic testing for genes related to a variety of mutations. That would have been a blood test I think.

NHMike wrote:
MGH does the testing on-site - they don't send it out. So they may have more flexibility. They did mine for free too.

[/quote]

The Guardant360 testing appears to be genetic testing for genes related to a variety of mutations. That would have been a blood test I think.[/quote]

Yes, it was a blood test.

Great news!! Apparently Yale went forward with the Oncomine testing despite the insurance denial!! They have the results and have shared them with my husband’s local oncologist....we meet with him Friday to discuss....we also head to Yale in 1 week to meet with the Phase 1 director there....Yale will deal with the insurance company! Yay! So happy right now....
Thank you everyone

jep wrote:Great news!! Apparently Yale went forward with the Oncomine testing despite the insurance denial!! They have the results and have shared them with my husband’s local oncologist....we meet with him Friday to discuss....we also head to Yale in 1 week to meet with the Phase 1 director there....Yale will deal with the insurance company! Yay! So happy right now....
Thank you everyone

Great news!!

Great news! I started to read your chain and was getting upset because as you know, I am being treated at Yale but also work there so I know they would never not do the testing and I was about to get angry for you . Hope the results help!
Brenda