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Petitioning for Coverage of Disputed Treatments|
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Army hospitals, and most military health care systems, usually have one MD assigned as a "primary care provider" for each patient. This is the person that needs to refer their patient to a specialist. If they do not cooperate, then go to the hospital administration. If EVERYTHING fails contact the patient's congressman.
At present the military medical care is in a state of flux, particularly with regard to the retirees, who had been promised full medical care "just like on active duty", which may not be in the process of being delivered.
Petitioning for Insurance Coverage disputed treatments
There is an organization called the National Patient Advocate Foundation that may be able to help / provide resources for patients with insurance problems, including problems with clinical trial coverage. I think their website is http://www.npaf.org
The insurance company rejected claims for treatment for the ET743 Clinical Trial. We had our hearing last night. Even the local oncologists went to the hearing with us! I guess the next step is to appeal at the state level. Does anyone have any other ideas that we could use to get this covered?
1) Take a look at this NIH site titled, "Clinical Trials and Insurance Coverage: A Resource Guide":
2) If your insurance carrier is already covering clinical trials in other states, they may find it harder to reject your claim. Here's part of a press release from 16 Dec 1999 - more than a year ago - that mentions a number of states requiring insurance coverage. Note, also, the number of major carriers participating. The reason they're doing it is that it's good business - finding better medicines will reduce their overall costs and clinical trials is the only way that new medicines can be evaluated.
The American Society of Clinical Oncology, representing 14,000 cancer specialists, today called on insurance companies nationwide to immediately follow the lead of companies operating in New Jersey and cover the costs of patient participation in cancer clinical trials.
The news that Oxford Health Plans, Aetna/US Healthcare, Cigna HealthCare and Prudential HealthCare would cover the costs of patients participating in clinical trials for experimental cancer treatments that have been sanctioned by federal health agencies was reported in today's New York Times.
"It is high time that cancer patients nationwide benefited from promising new therapies offered in clinical trials," said Dr. Joseph S. Bailes, President of ASCO. "These companies should be applauded for recognizing their role in encouraging cancer patients to participate in clinical trials."
"Companies are seeing the writing on the wall. Coverage of cancer trials is seeping into Medicare reform legislation, budget agreements, the Patients' Bill of Rights, and state laws, including those in Maryland, Virginia and Illinois. In addition, the Department of Veterans Affairs, Department of Defense and United HealthCare have all reached agreements to cover cancer clinical trials. This is now a trend, and other insurers and Medicare should sit up and take notice," said Dr. John Durant, ASCO Executive Vice President.
Here's a link to a more recent press release regarding insurance coverage for clinical trials along with an excerpt from that press release.
PHS Health Plans Extends Coverage to Clinical Cancer Trials
"September 27, 2000, Shelton, CT -- PHS Health Plans will begin covering federally approved clinical cancer trials for its commercial members in Connecticut and New York, effective today. Coverage will now include routine care for cancer patients enrolled in Stage I, II and III clinical cancer trials at health care facilities and physician offices in the PHS Health Plans network."
"To qualify, PHS Health Plans members must be enrolled in a clinical trial that is approved by at least one of the following organizations: The National Institutes of Health (Stage I, II, and III); The United States Food and Drug Administration, in the form of an investigational new drug (IND) exemption (Stage I, II, and III); The United States Department of Defense; or The United States Department of Veterans Affairs."
Dad is retired from Caterpillar and has an appointment with Dr. Demetri, the insurance company said they would not pay for ANY treatment or office visits...they said they wouldn't even cover surgery
1) Ask your dad get the denial in writing including specifically (citing chapter and verse) why they say it isn't covered.
2) Review the Summary of Coverage booklet that's provided to every employee or retiree and see if the reason for denial matches the summary.
3) Most Summaries of Coverage make reference to the insurance contract between the employer and the insurance company. In most cases the employee or retiree is entitled to request a copy of the insurance contract. If not, then it can probably be reviewed on Caterpillar's premises. Review the contract.
4) Contact Caterpillar's Human Resources (Personnel) Department and see if they agree with the insurance company's interpretation of coverage. If not, they should help your dad get the decision reversed.
5) Was your dad a union man? If so, the union will help him.
6) See if your state's insurance department will help. What state does your dad live in?
7) See if you can get any help from the Patient Advocate Foundation.
Patient Advocate Foundation
753 Thimble Shoals Blvd, Suite B, Newport News, VA 23606,
Phone: 800-532-5274 Fax: 757-873-8999.
Subject: Re: Insurance
Also check with your insurance and with your benefits dept. LMS is complex enough that often you can ask for, or insist upon, a case manager. Here is a little excerpt from a friend of mine at a national insurance company:
Just wanted to send a few tips on working with your health plan and requesting a case manager.
If your health carrier is the same carrier that you had when the patient was originally diagnosed and treated, you should have a very easy time persuading the health plan to assign a case manager. You may even get the same nurse. If not, you might want to put together a written request for the current health plan, to document the original treatment plan. Just remember to stay as calm and unemotional as possible.
They'll know how urgent this is and work with you to find the best solution.
Many health plans automatically assign a case manager to complex cases.
I'd suggest calling the health plan and finding out how to contact case management directly to determine whether they have an automatic assignment protocol, or if you need to request the case manager.
Check with Customer Service and or case management to find out how to select or help in the selection of an oncologist. Find out if you are absolutely restricted to a limited network of physicians, or if you can seek services from a wider network of physicians. You may want to do a search to find out if there are resources available to help you shop for a specialist; look for personal recommendations, and don't be afraid to schedule an interview process.
If you're contemplating alternative treatments, ask whether any alternative/eastern medicine services are covered, or if there are any discount relationships with alternative/eastern medicine practitioners available. Blue Cross and Blue Shield of Minnesota has recently established an alternative medicine network of providers with whom the plan has negotiated discounts for services. Minnesota subscribers can access alternative services directly, without a referral, for the negotiated discount amount. California is so far ahead of the Midwest on this stuff, its possible that your health plan has a similar arrangement.
Ask the patient's current physician if he/she is comfortable working with you to find the specialists that you are confident about. Ask him/her to recommend a specialist that they would select if they or a family member needed services. Good bedside manner is nice, but you may want to make sure that everyone understands that you want honest, complete information.
Speaking of complete information, Mayo Clinic has a website, and they allow you to register and ask questions of the specialists. They might even be able to make a recommendation on specialists in your area. It might be worth your while to investigate this resource, if you haven't already.
If you hit a total roadblock, find out what the patient rights are in your state. Every health plan has a patient/member bill of rights, and many of them are based on state mandates. Find out if there are any advocacy groups in your vicinity, and check with the Commissioner of Insurance for the state, to find out if there are any mandated appeal provisions at the state level that you could pursue.
I hope that this has given you a little help.
Dealing with Medicare
Date: Tue, 18 Dec 2001 From: Margaret
Subject: Emergency Medicare Question
I have an emergency and only have a few hours to figure it out - Georgia was on Gemzar for two months and then on Navelbine for the past three months. We received five letters yesterday from Medicare stating that they had reviewed her case and none of these chemo treatments were going to be paid for! They said she did not fit the criteria for these chemotherapies. The Navelbine has brought stability to tumors that were otherwise doubling in size in less than two months.
I've called Medicare but they said that they had reviewed the case twice and the same decision was made. Georgia's due to have her next treatment today - in six hours. Any suggestions before we get to the doctor's office and face this dilemma?! Please write to me directly at so I can receive any advice you have to offer immediately.
Date: Tue, 18 Dec 2001
Subject: Medicare dilemma
Great news! I spent several hours on the phone with Medicare this morning, working my way up the ladder of authority. Finally I reached someone who was sympathetic to the situation and did more than say they were sorry, there was nothing more that could be done. I explained that lms was an extremely rare cancer and there was no "gold standard" for it. I explained that the chemos they were denying were actually working and saving Georgia's life.
She asked the name of the cancer and looked it up - nothing. Then she asked where the tumors were located and I told her. She did some extensive research and found out that by coding the bills in a slightly different way, they would be paid! She even went so far as to call the gal at the billing office and explain to her how this needed to be done! When we arrived at the oncologist for Georgia's chemo treatment he told us that he would have gone all the way to court to fight this for her and would never have just cut off her treatment. But he was extremely thankful that we had pursued the matter and found the simpler course of action. So Georgia got her chemo, the doctor was happy and the day was good. Thanks to everyone who responded with wonderful advice and experience. You're all the greatest!!!! Margaret
What arguments did you use?
I explained repeatedly as I worked my way up the ladder of authority that lms was an extremely rare disease with no "Gold Standard". The few chemos (Adriamycin and ifosfamide) they had listed as approved for this disease were far more harmful and less of a chance of working than what Georgia was already taking. I also had the advantage that Georgia had just had a CT scan showing that the Navelbine was indeed providing stability to tumors that were otherwise growing rapidly. The manager I finally spoke to last asked where the tumors were now. I told her that they were in the retroperitoneal area and left lung. She did some extensive research and said that if we billed it as a "peritoneal neoplasm" instead of lms, it would get paid! She even called the doctor's office and explained to the billing office how to do this. I'm sure it helped a bit that my background is in health insurance, and I'm sure it helped even more that I simply would not take no for an answer. When we got to the doctor's office that day, both he and the billing gal thanked me profusely. He said that he was going to appeal the decision and would have gone to court to get this paid if need be. He would not have stopped the treatments, and for that I was thankful. But he was very appreciative that he would not need to spend hours of his time battling this obstacle. In the end: the bills get paid, Georgia gets her treatment, and ol' Margaret ends up feeling pretty good about herself - not bad all in all:)
The Official U.S. Government Site for People with Medicare
THE PATIENTS' BILL OF RIGHTS IN MEDICARE AND MEDICAID
Medicare Consumer Information
The web page at
has links to a collection of government publications on Medicare
Last update December 2001 doctordee
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