Foundation Medicine test denied

[bethdavis]

Any tips for getting the Foundation testing approved?

I have excellent insurance and it has been no problem getting everything covered. The day they received my husband’s blood sample, Foundation called and asked several questions and told us our insurance had approved it, and received verbal approval from us.

Insurance denied it. Foundation appealed, and we just received the letter of denial. It says it is a “first level appeal” and that there is not enough evidence found in the medical literature to show that this testing is effective, so it is therefore not medically necessary.

I am sure some of you must have had a similar denial. Could you please share if you were ultimately successful? And any supporting evidence?

Thank you. It’s $5800!

[Concerned-wife]

No personal experience in our family. Not much info in your profile. The reason I mention this is because coverage appears based on mCRPC. You can look up Medicare policies, which a lot of non Medicare companies base their coverage on if you know the billing code. Foundation should be able to supply the info to you and help you appeal. In the meantime, I found this document which might help. ( it does appear to be one year old) fightcancer.org/sites/defau...

[treedown]

I had a test with a different genetic company, Insurance paid a large amt and it still left $5k unpaid. I appealed directly to testing company and based on amt paid out of pocket that year and releasing rights to data they wrote it off. I think I paid $100.

[HerbieP]

I too had mine declined by insurance, seems much of the genetic testing is like that based on my experience. I was able to get the hospital to let me pay it off over time with 0% interest. Reach out to the financial folks at your hospital/clinic and see what they can do for you.

[MateoBeach]

I have not had it yet. But I do know that genetic testing is now recommended as part of the SOC guidelines for all men with advanced prostate cancer. Appeal again is what I would do with a letter from your MO (that I would write for him) that made the case and quoted the guidelines, etc.

[NotAlwaysSunshine]

Our Aetna insurance denied the Foundation test which my husband decided not to get. The cost was ?? I think maybe 7K. We did do the genetic testing ( 2 years ago) - the cost was 2K. Insurance did not cover.

[Yadifan]

We had foundation one testing done last fall. We received a phone call this week from their office. They submitted it 3 times to insurance and each time it was refused. They're sending a financial questionnaire to us and told us that the self pay will be less than $4000. I think if we're responsible for payment, they'll work with us. I was disappointed that our insurance (BCBS) wouldn't cover it. It was ordered by our physician and was an important test to help guide us. They sound like they really try to advocate for us. Not sure if financial help is available to make the self pay less of a burden. I imagine there is something if you qualify. Can't imagine the need to complete a questionnaire if there isn't. Haven't received it yet. Don't regret having the test done regardless of how much it ends up costing.

It is irritating to have to follow up on all the things. Medical billings-wrong labs ordered-prescription refills-preapprovals-referrals. The cancer is hard enough. The other stuff is just bullshit. Wish I had better news to share with you.

[bethdavis in reply to Yadifan]

Thank you! It’s strange because Foundation originally told us that it was covered. If it is income based we probably won’t qualify, but perhaps they will meet us part way. Thank you!

[Chugach]

They have a program that covers the cost of testing when insurance won’t cover it. It’s just a form your MO should submit

[Chugach in reply to Chugach]

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