I’m wondering if anyone has had a similarly similar experience.
i have stage 4 prostate cancer. Soon after I started treatment my oncologist referred me for radiation therapy. I had 10 rounds of treatment. Fast forward 6 months and my insurance company starts denying them as “not medically necessary” and “Experimental or Investigational in nature.”
Now I may be on the hook for $45,000 of claims.
I did reach out to the radiologist staff and they forwarded to relevant department. Fingers crossed. I have also filed an appeal, but frankly have little hope that will help.
Has this happened to you? How was it resolved?
thanks,
Joel
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jedimister
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I'll just comment - I've read a number of articles recently about medical insurance companies turning claim approval over to AI routines, which automatically deny a certain (sometimes significant) number of claims. They even deny them after your doctor files an appeal. They have doctors on staff who just sign off on the AI generated refusal. The apparently logic of the AI denial isn't really medical need or necessity - it's if it thinks the insurance company can get away with the denial.
Apparently the trick is to get a human being to review the claims.
I'm guessing this is some form of commercial medical insurance (or Managed Care Medicare). I believe traditional Medicare would not have denied it unless it was grossly inappropriate treatment.
Medical claims coding, its an art not many have achieved. Thus denials of perfectly proper treatments.
Cigna refused my RT saying it was medically unnecessary. After 3 rounds of appeals they finally paid. Don’t know what the appeal process is in your state but in Vermont there can be 3 rounds of appeals. The first 2 are internal appeals within the insurance company. The third is an appeal to an external independent arbitrator. The first 2 appeals were by my RO. Of course they were declined. The third appeal was submitted by me. I just submitted the same information my RO had previously sent to Cigna but this time it was successful and Cigna paid.
What state do you live in? Contact your state insurance commissioner. Engage your senator if necessary.
A few years ago my insurance denied a radiation claim. Upon investigating I found out that it wasn’t the treatment they denied, it was the charges for the doctor setting up the treatment plan. I asked a customer service rep who in their tight mind would have radiation treatments without a doctor setting things up? The gal said, “well I think you could.” Appealed and after months they paid it.
Sorry to hear this and I don’t mean to cause you further angst but I (and I believe my MO) wait for insurance to approve a procedure, scan,… before going forward. Do you know why your MO didn’t do this?
This is a frustrating aspect of the whole drama. For all the labs, scans, biopsies etc. there were several "waiting for authorization" steps. My meds were changed because insurance wouldn't cover what my oncologist wanted to prescribe. One one occasion they asked me to all insurance and verify coverage. Frankly the thought that radiation treatment would not be covered never crossed my mind. They do have a "does not require pre-authorization" on record.
I can’t believe the radiation therapy did not get approval before proceeding. That is rediculous. We gave people expensive infusions. We never gave one without knowing whether the insurance company would pay.
I have denials of new imaging technology and had to go after them several times, finally writing them myself after doctors ran out of road. I told them that it was FDA approved and the standard of care and that their refusal amounted to malpractice and was putting my life at risk...they approved it.
Don't know if that might work but you need to keep after them and follow all their required steps. The healthcare providers are obligated to get authorization before the imaging is done or let you know it was denied. You have more leverage if you fight them before doing anything. If they did not inform you that it was not covered, I would also go after the place where the imaging was done.
It really sucks to have to do all this on top of going through procedures but you and hopefully a loved one need to continue until you get a real person and make them shake a bit about the liability.
"Soon after I started treatment" What treatment? Surgery, ADT?
"I had 10 rounds of treatment" Primary, adjuvant, or salvage? Was that the full dose or are you saying they stopped paying in the middle of ongoing treatment?
I think they look at the standard progression of treatment and expect us to go through the steps succesively. If they see something they think is out of order they may deem it experimental.
I may be looking at a second round of salvage RT after surgery and initial RT. Kinda worried Medicare/United may say enough is enough.
I notice on my monthly summary of benefits which I received in the mail well after the treatment protocol (MRI-linac RT 5 treatments plus SpaceOAR) that Aetna (Medicare Advantage) paid out what they chose to which was most everything except denial of some not all of a Description of Service called "Radiation Therapy Dose Plan" which the facility entered multiple times during the treatment protocol which took a 3 months including SpaceOar. The denials did not generate a bill of any kind to me. All of the treatment steps required pre-approval which the facility handled with no problem. Also Aetna approved the whole treatment as in-network even though I live in Atlanta and had treatment in FL which was the closest place that had the specialized MRI machine necessary for this particular treatment. The facility also handled the initial in-network approval, I didn't have to do anything.
On a side note I recently was fitted with an oral appliance for sleep apnea and the office made me sign a form stating I would be responsible for the difference (of $1600 ) between what Aetna approved ($2K) and what I initially paid ($400) if Aetna denied the already approved claim, since they have had this happen with many different insurance companies denying claims that had been previously approved. Apparently if you get an over the phone approval from a CR it might be wrong and the doctor's office had to draw up the letter for patients to sign to protect themselves from this. Aetna paid no problem in my case.
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