I am wondering if anyone had to appeal a denial on a predetermination letter for this proceedure? While I was meeting with Dr. Vipul Patel and him accepting me as a patient, the letter was waiting in my mailbox back home. Dr. Patel literally does more of these than anyone in the world, he tracks his patients, orders Penile Rehab and Pelvic Floor rehab, and cares about what I care about. He has an active support group, does research, and follows his patients long term and has evidence that his technique is effective. So why deny ? I am not even sure the most effective way to approach an appeal.
Is Radical Retropubic robot assisted ... - Advanced Prostate...
Advanced Prostate Cancer
I had a well known robotic surgeon from a cancer research facility in Buffalo NY tell me surgery wasn't a possibility. Before that I had several doctors say the same from not so well known facilities. My last stop was a world renowned treatment facility with a world class urologist and a successful open prostatectomy was done.
Ask your local doctor for a referral and not only should they have no problem giving it but should encourage it. Don't stop because one door is slammed in your face if you feel it's what you want. With this disease a very big part of successful treatment is making things happen for yourself. If you do see another surgeon make sure it is a specialist. There are no guarantees with anything but it will only help to aid in no harsh side effects. I think nerve sparing is overrated as it seems very few come out of a prostatectomy without that issue.
The surgeon will tell you why he denied you. Doctor's, like all of us here have opinions. You can accept them or reject them. I'm not sure of your current health or what the initial prognosis was but there are still more doctors than not that go with the outside of barn door theory. Maybe if not far advanced he may think it would be your benefit for watchful waiting. Give some details and I'm sure plenty here will give their opinion on why you were denied surgery.
I had a denial letter for Cyberknife and ultimately prevailed.
I got a hold of the letter that the doctor received from my insurer that explained exactly what their reasoning was.
They said it is considered experimental for Gleason 7. I had to have GL 6 for them to pay for cyberknife.
They have guidelines for everything which the patient doesn’t get in a handbook. Only when you try to get pre approval will you have access to their guideline for that procedure if it’s denied.
You should ask for it and it will state all the conditions that need to be met to get the procedure approved.
In my case, the guidelines said cyberknife is approved for up to 4cores of GL 6. I appealed. Said I had 2cores: a 6 and a 7, in good health, early stage, etc. and sent copies of studies showing good results for GL 7. They agreed to pay for the procedure. (It’s important to get them to see you as a person. I said in my appeal, “this is cancer. It’s been 3 months since diagnosis. Time is of the essence”).
Long story but get their guideline on why it was denied. It’s not a secret. Address every point and counter each point with a sound rebuttal. To learn more, google The Insurance Warrior.
My guess is 1 core of GL 6, is the reason but I don’t know.
Do you have advanced prostate cancer? It IS experimental for that situation.
No. Gleason 6 with a second opinion on the pathology that confirmed. PSA of 4.7, but Prolaris score of 4.2 which is “more aggressive”. Based on exam and path they believe it is fully encapsulated, but I got a 3T MRI two nights ago. Waiting for results. I have a nice letter in hand from the doc now, just need ammunition since they can probably stick to their guns on the experimental part.
"Radical Retropubic robot assisted prostatectomy with nerve sparing"
I don't know how that different from other types of robotic surgery. The insurance Co will put in writing why it is. You need to get your doc to put in writing why it isn't.
I wouldn't blithly assume you will agree. They can talk a big game to you in private, but if they won't put it in writing, then you aren't being fully informed.
You need to look out for yourself. They both have interests that may diverge from yours.
But in any event, if you want to appeal, you want to do it with that letter from your doc. Only he can provide a well reasoned and articulate rational.
He did provide one, including citing the importance of surgeon skill, and track record of doing 12,000 of these.
No no no no no
It is not about his skill
It is not about doing a procedure a million times
It is about whether it is medically appropriate in your particular circumstances.
There is a Medicare appeal process. There is a private insurance appeal process (at least untill they repeal Obamacare).
If he has successfully done 12,000 of these to patients in your circumstances, you will win the appeal.
It seems improbable that that is the case. Is that the case?
If he has done 12,000 of these to patients like you, and it is innovative. He will have written it up in some journal. If it is not so innovative, others will have written it up.
Does his letter cite any journal articles by him or by others?
If it doesn't, that's a real real problem. And it is a red flag of some type of deficiency somewhere on your side of the equation.
If he failed to include the citations, ask him for them. If they don't exist, maybe you need to get a few second opinions.
The letter from Patel includes a dozen or more citations. Fingers crossed.
That's what you need. And that is what will get you what you want if you appeal.
Most appeal processes have a fast track, but to access it, your doc may need to write a second letter with a specific phrase of urgency.
Don't forget you have multiple steps of appeal.
Sounds like you are still at the insurer level.
You do get to have an independent decision maker if the insurer declines.
And actually you eventually get to have a Judge decide.
Pay cash if Patel is who you want to do the procedure. I had Ahlering do my procedure and he doesn't take insurance. $7,000 is cheap when you are talking about your life!
I would do that, but 18 years ago I knew someone who negotiated a $25,000 bonus to pay for his. I assumed it would be prohibitive. Thanks for the reply. Are you happy with your results?
I was a Gleason 8. Ended up having a small <2 mm focal margin on prostate during pathology but was pT2. At 12 weeks PSA < 0.02. No ED and no incontinence now at 6 months! Next PSA test in November. Paying cash for a top rated surgeon who has done thousands of surgeries was totally worth it.
You appeal through your Doctor. Give him the letter and have him write the response.
Thanks. I took a parallel track and did just that. I saw it show up in my email while traveling to another state and had not been able to act on it yet.
Good. In every case, all insurances denials which I have experienced in the past 15 years dealing with this bastardhave been resolved by my medical professionals. And, I have had my share of so-called exoerimental treatment. As my research Medical Oncologist told me...... their Physician will have to talk to me and I guarantee you that my credentials are much stronger than theirs...... too many in the medical profession have neither the training nor experience to be knowledgeable in all treatment protocols available. Good luck.
It's inconceivable to me that anyone at this stage of the game would consider robotic prostatectomy experimental for a Gleason 6 localized cancer - which is what your profile page says was your diagnosis. What treatment would the insurance company accept, open surgery? That's insane.
Is it possible that your insurance company thinks that "active surveillance" (AS) is more appropriate than surgery? Have you discussed AS with Dr. Patel or your local urologist? Do they agree that surgery is warranted?
What insurance company do you have?
I think you should certainly appeal this. Try to get someone on the phone from the insurance company to find out what's going on. They may just send you a form to fill out but that could go back and forth delaying and delaying and only later do you find out what they thought (or claimed) the problem was.
It's awful to go through insurance crap on something like this. I think persistence is important. We all wish you the best of luck with it.
Thanks. Dr. Patel has done 12,000 of these. I have the opportunity to be cancer free and not treat this as a chronic disease, or risk metastasis, or even extra encapsulation that would make Nerve Sparing no longer an option. I have Cigna PPO but we are administered by a company health plan with an overarching set of rules and administrative oversight. Dr. Patel tracks his outcomes and his technique addresses the desire for best outcomes for the urethra and sexual health. He is posting better numbers than any option available to me that gets me the three things I want. I may have to wait 12 months for nerves to recover, but this doctor prescribes Penile Rehab, Pelvic Floor Rehab, and has a monthly support group. The first surgeon I talked to sea his job as curing your cancer, doesn’t follow his patients, and wouldn’t know if he is getting results with his technique or not.
to jazz2cool, Give us a little more info regarding your Pca so that the experts here can assist you. Also see a good Oncologist who specializes in Pca.
Good Luck and Good Health.
j-o-h-n Thursday 10/18/2018 4:44 PM EDT
PSA of 4.7, G6, but 4.2 on Prolaris which makes this a more aggressive form of cancer. No extra encapsulation. Should be easy to spare nerves now vs. later as things progress.
Am I missing something or is this just a robotic prostatectomy that the insurance is objecting to?
They can't be objecting to that. What exactly are they objecting to?
What is their stated reasoning?
It can't be that they insist he do by hand instead of with a robot? What exactly is their stated issue?
"We are in receipt of your request to review the Laparoscopy, surgical prostatectomy, retropubic radical, including nerve sparing, includes robotic assistance (55866) is not covered by the plan because radical retropubic prostatectomy is considered experimental and investigational due to insufficient scientific evidence demonstrating their value in the management of individuals with erectile disfunction following radical retropubic prostatectomy. Therefore we are unable to approve your request.
Page 34 of the Heart Options Component Plan and Summary Plan Description states the following exclusion:
You could read this several ways, but I do not currently have ED. I would agree nerve sparing is useless if you have ED. It is not all that clear what they are saying.
It could be coded wrong. It doesn’t say anywhere in there “for prostate cancer”.
Perhaps, the code for the condition doesn’t relate to the code for the treatment.
Ask how it is being coded? Call and ask the insurance company what is the condition (the doctor reports). It is very simple. They will just look up the numbers. Maybe the surgeon’s office used the code for ED instead of code for PCa.
My hunch is they will find a mid-match.
I don’t understand why it was denied. It’s hardly experimental unless being done by a novice! But you shouldn’t be afraid of open surgery either. It has similar results in the hands of an expert and in my case I was playing golf in three weeks after open nervesparing RP at Johns Hopkins.
Thanks for your reply. In dealing with them with my cancer, I have found almost anything that goes to them for predetermination gets denied. But I had my surgery Dec 2018 and am doing well. No incontinence and only mild ED. They learned that I was not going away easily and eventually approved it.
Not what you're looking for?
You may also like...
at age 66. Any advice on dealing with this side effect is appreciated. Been doing kegels for two...
scan showing one spot on his spine now has him at stage 4 and about to put his body through...
from being an RN to being an RN/patient, and all of the health care professionals I have dealt with...
First phone visit with academic hospital on my biochemical recurrence post robotic radical prostatectomy (University of Wisconsin - Madison)
default standard approach in Wisconsin even though some of the literature suggests ADT does not add...