Insurance denying coverage for Radiation

[DD50]

Last spring I was diagnosed with prostate cancer: Gleason 10 on all cores, with single bone met and one swollen lymph. PSA of 22. Immeidately put on hormone therapy shots. After 6 treatments of taxotere over basically 18 weeks, scans showed "no evidence of osseous metastatic disease" and lymphs normal. Currently PSA is .18. Great news. Oncologist sent me to radiology for follow-on radiation treatment but BCBS of Illinois denied the pre-auth. The radiation oncologist had call with BCBS, and informed me that they still denied her. My next step is to appeal BCBS Illinois directly.

This seems like it's case-by-case basis(?) or state-by-state? I thought I had read posts somewhere that insurance did cover follow-on radiation, and in some cases after appeal. My question for any of you is: are you aware of cases where insurance has covered radiation for prostate cancer as follow-on treatment to chemo? Or cases where it was denied but then later covered after appeal?

[Tall_Allen]

That is going to be hard to prove. I think the best way to make your case is to highlight the STAMPEDE trial that showed the benefit of debulking the primary in newly diagnosed men:

prostatecancer.news/2018/09...

But if you are close to any of the 257 US locations, you should qualify for the clinical trial that allows previous systemic therapies:

clinicaltrials.gov/ct2/show...

[Tall_Allen]

No, I meant that it's going to be hard to prove to an insurance company that debulking the prostate with radiation is still an effective therapy after systemic treatments have already been used. The only data we have as proof is among newly diagnosed patients.

[fmenninger in reply to Tall_Allen]

Want proof....That’s me!!!

[DD50 in reply to fmenninger]

What treatments did you have?

[fmenninger in reply to DD50]

Newly diagnosed back in Jan and treated with zytiga, Lupron, (adt) and 28 sbrt radiation to debulk prostrate area which included SVI and some LNI.

[fmenninger in reply to fmenninger]

Was considered oligometastatic and treated both AdT then radiation

[DD50 in reply to fmenninger]

Thanks fmenninger. What's your PSA now?

[fmenninger in reply to DD50]

To date, nadir at 0.2

[fmenninger in reply to fmenninger]

Who are you doing and did u resolve BCBS insurance issue?

[treedown in reply to fmenninger]

You don't mention having Chemo first before radiation which was TAs point, I believe. Did you have a systemic treatment prior to radiation?

[fmenninger in reply to treedown]

Sorry...yes. systemic adt with sbrt

[Hidden in reply to fmenninger]

With terrible defensive skills

[fmenninger in reply to Hidden]

It’s called the BHL, beer hockey league , with Matidor defense. Ha ha. If we get this prostrate awareness inline skate, can I count you in?

[Hidden in reply to fmenninger]

I'll come up and watch..I don't inline any more. Ice and I'm in even in NY

[fmenninger in reply to Hidden]

It would be in Wilkes barre pa area and rink is in mt top

[Hidden in reply to fmenninger]

Ok. Been to both. Mountain top is off the pocono exit of the pa turn pike 2 hour drive at most for me. Let me know the date

[fmenninger in reply to Hidden]

Great! I will let you know as we are hoping to do this in mid to end of April

[treedown in reply to fmenninger]

Not sure if ADT is considered systemic and may well be but it is not the same level as taxotere which is a chemotherapy. The follow up of radiation after chemotherapy is the issue here.

[Hidden in reply to treedown]

ADT is systemic treatment vs targeted treatment like radiation.

[treedown in reply to Hidden]

Thanks I did not doubt it.

[fmenninger in reply to treedown]

Most definitely ADT is systemic and yes is different from chemo. What’s the difference of ADT then radiation vs chemo then radiation as again both chemo and ADT are systemic treatments?

[treedown in reply to fmenninger]

The only difference I would point out here is the insurance company pays for radiation after ADT but apparently not after Chemo. Also I believe TA says there's no science showing a benefit which is why the insurance co is probably denying it. If no benefit there really is no reason to put your body through it IMO.

[fmenninger in reply to treedown]

To boot, I too have BCBS and live in NY and had no issues of denied coverage based on mskcc treatment strategy.

[DD50 in reply to treedown]

I said in my post " Immeidately put on hormone therapy shots. After 6 treatments of taxotere over basically 18 weeks, scans showed "no evidence of osseous metastatic disease" and lymphs normal. "

[Tall_Allen]

The study from Mayo suggested the opposite- there was no benefit to treating oligometastatic bone metastases. But that was in recurrent patients, after treatment of the prostate (RP or RT), not in patients who have not received prostate treatment.

[fmenninger]

Gotcha. Are all rinks in pa closed now???

[fmenninger]

Are all finks in pa closing?

[User2008]

Appeal it again. My husband's subsequent radiation was approved by BCBS 5 years ago. Please don't give up.

[j-o-h-n]

Greatings DD50,

Please tell us your bio. Age? Location? Treatment(s)? Treatment center(s)? Scores Psa/Gleason? Medications? Doctor's name(s)? Thank You!!!

All info is voluntary, but it helps us help you and helps us too. If you do respond, copy and paste it in your home page for your use and for other members’ reference.

Good Luck, Good Health and Good Humor.

j-o-h-n Tuesday 12/15/2020 5:55 PM EST

[Fanger1]

You may want to ask your MO and RO to run additional serum testing for circulating tumor cells. If they are present in your blood that is further evidence that you cancer is still active. That data can be used in your pre-athorization narrative. Best wishes for getting treatment approved.

[DD50]

Well, my insurance changed the company that they were using for pre-approvals / screening. I hadn't completed the appeal paperwork and since my insurance is no longer using that company, there was no point in sending all of the appeal paperwork along to them. So my radiation oncologist's office (re)submitted the pre-approval request, and it was approved this time. Thank God. The office said that they pretty much denied everything at the end of the year.

Anyway, I read the STAMPEDE study (thank you Tall_Allen) and it seems to indicate that radiation after chemo was significant/worthwhile in cases of low metastatic burden, of which I was/am in that category so I'm hopeful that this will be worthwhile. If any surprises come up with insurance, I'll have that study in my back pocket for the appeal narrative.