The plan was to treat 2 mets on the spine and it was denied because I do not meet the criterion:
"you must have a severe symptom or serious threat to your life from the cancer in the location being treated"
Its one fight after another. W/O insurance its about $50-60K
They approved EBRT to the prostate.
Anyone going through the this battle?
Bob
Bummer! I don't have any great advice. I do try to mention any pain I'm feeling as frequently as possible so it doesn't come as a sudden surprise when discussing treatment or negotiating disability leave from work.
I was fortunate...My RO at UPMC went through the appeals process and a third party overturned the insurance company's denial....You can appeal this decision.... While SABR-COMET was a trial involving 4 different cancers, prostate cancer was in there...Talk to your RO....see if he will go to bat for you....Good luck....Keep fighting...
Fish
Thank you NP, Will discuss case w/ RO when he's back from holiday. Bob
Bob,
Best of luck...don't take no for an answer....read the SABR-COMET trial results...
Fish
Thank you NP, I have read it and its the reason for pursuing both SBRT,IMRT treatments. I'm in the middle of writing the appeal. Submitting it to my RO today. Bob
Submit it to him on a thumbdrive with the typed version you have and it will make it easy for him to revise the written version, give it to his secretary for final revision, and put it on his letterhead....this forces them to deal with him, and the MD's who handle the appeal process don't like that....dealing MD to MD...tell him to tell them he wants to record the phone conversation of the appeal review...they really hate that stuff...likely, it will get overturned...
Fish
Just tell your oncologist you have severe pain there and you are at risk for spinal compression fractures, and resubmit.
Thank you TALL. Will see what the RO wrote on initial request. ob
1. Appeal. You have multiple levels of appeal.
2. Tall Allen has a good argument: "Just tell your oncologist you have severe pain there and you are at risk for spinal compression fractures, and resubmit", but you need your doc to put it in a letter format. Then use that letter to appeal.
I don't know where you are but I know there are a few radiologists who bill for EBRT but actually use SBRT. Ask around. I got the impression it's not that uncommon and not just applicable to Medicare. Many insurance companies have the same approval guidelines as Medicare.
My RO had to go to bat for me for the EBRT because that was rejected. "not necessary". That has been cleared up. Thanks Bob
Have you discussed the rejection letter with your MO? If so, his response? If not, why not? The key to overturning any Medicare rejection letter is your expert and not a paper pusher.
Resubmission is in order. The fear and reality of facing spinal compression. Your MO should write a letter to accompany.
Gourd Dancer
Agree with Tall_Allen. Appeal it ASAP. Tell them you are having debilitating pain, and have your RO and/or your MO provide a statement that you are at high risk for fractures .
Agree with TA and Tom67. I used to put on a brave face when going to the oncologist, that is until I got a hold of my written visitation summaries by the doc. They painted a far rosier picture than things really were.
Now I let it rip when I visit him, and fill him in on all the wonderful side effects of Chemo and years of ADT, the joint pain, headaches, neuropathy, fatigue, cognitive issues, etc. and I get a copy of each visitation summary to make certain it includes my comments and is accurate.
As guys we were raised to suck it up, be tough and not complain and we are really good at it. That doesn’t always work out too well when battling cancer.
Ed
I can imagine an a-hole doctor drinking his latte and checking off a box "NO". No wonder some people go postal....
Good Luck, Good Health and Good Humor.
j-o-h-n Friday 12/28/2019 5:21 PM EST
Yep, j-o-h-n.....it isn't their grandfather, father, brother, son, cousin, nephew, etc... some MD who gets paid good money by the insurance company to say.."No" !!!!... and then they take nice vacations with all that "hard earned" money.......... The APC patients, all snug in their beds, with visions of "going postal" on money grubbing, insurance butt kissing Radiologists dancing in their heads.....
Happy Holidays,
Fish
They have covered my husband so far. If you are in pain, they should treat you with radiation. You might not get SBRT on the first round but you should get it if a palliative dose does not work. My husband is on medicare also and they have covered it 3 times. Good luck!
Thank you for your encouragement Carmen. RO will be in after the holidays and I requested that he process the appeal. Bob
How long does it takes to destroy à met after SBRT
Oligo metastatic BCR, looking for options.
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