So we’re nearly at the one-week mark of starting radiation treatments and I have yet to see any superpowers. Dangit.
We also got a letter from our insurance company, Blue Cross Blue Shield, informing us that they are denying coverage for my radiation treatments because it “does not meet the criteria of ‘medical necessity.’”
I have cancer. The tumor being irradiated is aggressive, as in incredibly fast growing. Where, exactly, is the dearth of “medical necessity”??
Obviously, we’re appealing.
And on the aggressive and fast-growing front, I can feel the tumor beginning to come back from where the chemo knocked it down. Right now, it’s just an uncomfortable pressure in my palate and against my last upper-right molar, but I remember this feeling. It will become blindingly painful in a matter of days unless the radiation overtakes it and starts pummeling it back again.
The radiation is slowing it. I don’t need painkillers yet, at least. In April, at this many days out after I finished with my R-CHOP chemo regimen, I was already taking daily painkillers and starting to ramp up the doses. And it was a week later that I went into the hospital for the first round of R-ICE chemo, needing dilaudid to manage the agony.
It’s a race to see if the radiation can hammer it back faster than the tumor can grow to a debilitating size. There’s no way we can stop in order to argue with Blue Cross Blue Shield about whether my radiation treatments are a “medical necessity.”
I have much fury, distress, and outrage.
I so wish there was something I could do about any of this beyond saying, I'm rooting for you, I have an unlimited basket of virtual hugs, here have a whole lot of them any time it may help. I'm so sorry you have to go through any of this and I will be sending poisonous death ray thoughts toward the idiots at BCBS who are causing you this vile, unnecessary additional aggravation.
hug hug hug hug hug hug hug hug hug hug hug hug !!!!
I cannot speak on behalf of BCBS, because I don't work for them, but to hopefully give you some insight on how these denials work on the insurance side, because I have to write this horrid letters for Humana.
Most of the time, even for insurance bought through the exchange, the denials are not because the patient's condition isn't bad enough but because there is a very specific set of criteria set that the insurance companies follow (that we are mandated to follow -the letter should tell you what criteria was followed -Milliman or otherwise), and it is up to your doctors and hospitals to submit the proper information to the insurance in accordance with not only with that criteria but the extremely strict mandates (state and federal timeframes) we have to follow in order to get an answer for approval or denial out by.
If we don't receive enough supporting information (or sometimes any) in the proper time, it gets denied. In your case, your doctor should be setting up a a peer-2-peer review with the BCBS Medical Director IMMEDIATELY and if they are not, something is not right there. You're in Georgia, right? Georgia has a no-take-back rule. Which means insurance is more likely to deny first and overturn to give approval later than risk approving and then denying your claim later if the hospital codes the claim wrong because we can't take that approval back once given.
Case Management departments issue denials for lack of medical necessity for more reasons than can possibly be explained in a short letter. If there is a contact phone # for a case manager on that letter, call it. Because sometimes the treatment options might be something they think are inappropriate. Yes, you your situation and so does your doctor, but something in the information received from your provider by the insurance didn't look quite right. So, be an advocate.
I work for a competing insurance agency. I'm not a nurse or a doctor, I can't give medical advice, but, I do work in case management and my job involves calling for clinical notes and writing those exact denial letters like the one you just received. I have had a lot of training on how the ACA and insurance in general works. If I can be of any help at all in any way, please... let me know.
Greatly appreciate your enlightening post.
Met with my radiation oncologist yesterday. He's totally going to bat for me with regard to appealing BCBS's denial of coverage ruling. He's apparently seen this before with BCBS and is confident that it'll be overturned, although it may take a while.
He's already done the peer-to-peer review, and BCBS's case review physician is completely in agreement with my doctor as to the medical necessity of my radiation treatments, BUT that doctor has no ability to overturn BCBS's denial of coverage decision (which does make one wonder what exactly the purpose the peer-to-peer step has in this process). So we're progressing to paperwork and standards submission, etc.
My oncologist indicated that the problem is that BCBS is using standards from 2009...because, of course, medical science--particularly in the field of oncology--doesn’t move forward at all in five years. [/sarcasm]
I don't know BCBS's policy but here -Humana, unless it is a written exclusion of the policy (which the ACA has eliminated pre-ex exclusions), in commercial case management, our Regional Medical Director's can overturn any denial that does not go directly against the contract language that was signed between the employer and the insurance company (so, you/spouse employer and BCBS/Humana whatever) or if private pay -then you and the company.
I know people bag on insurance in a general way, but there are a lot of differences in how companies handle things. I'm sort of curious what criteria they are following then. Are they denying maybe as investigational/experimentional? Sometimes if it is a relatively 'new' treatment option or change in treatment plans with not enough literature to support success options they get leery of covering it.
In which case it will get passed along, along with the RMD's notes, up through the Grievance and Appeals department. Which is a different department.
I'm very glad your doctor is pushing forward for you and I hope for the best. Another thing to look into, since I don't know what BCBS offers, but I know Humana does, is we have a specialty program which is called the Humana Cancer Program, a part of our Personal Nurse and Humana Cares programs. Basically you have a nurse advocate inside the insurance company to talk to directly. They work directly with their insured members to talk about concerns and such. I know we pioneered it years ago, but I heard a lot of other companies took on similar programs.
Something to look into.
Actually. Let me work my magic. I'll do some digging today and see if I can't find anything out for you about the BCBS system, if they have any comparable programs. I don't know if you'd qualify for any, but it might be something to call about, you'd at least have names of things to look into, at any rate.
Anything you can find out about a patient advocate contact from BCBS would be greatly appreciated.
And yep, they're denying it as "investigational" on the basis that it's IMRT (Intensity Modulated Radiation Therapy), despite the fact that IMRT has been around for over a decade and is the standard for head/neck cancer treatment in order to better safeguard all the sensitive surrounding tissue--brain, eyes, pituitary, thyroid, and salivary glands--from damage.
Matthew is taking lead on the phone wrangling, but it's my radiation oncologist who is spearheading the appeals process. Since he's had experience with it and knows what medical standards and red tape lingo to proffer up, this fills me with great relief.