Avastin only if you're an outpatient?!?

(cross post from Insurance board) Hi everyone, my husband is currently in very bad situation. Brain stem tumor recurrence, progressing with more enhancement and was admitted to major cancer center in NYC for 2 1/2 weeks. During this time, they sought to get approval for Avastin and were denied. What?!? My husband is not well enough to be at home. They informed us that Avastin is only covered if the patient is at home and going to outpatient clinic. He was discharged to home and we arranged 24/7 home aide, and next day taken by ambulance to local ER after sudden edema caused falling and slurred speech. Tomorrow supposed to be transported back to NYC. Is this true about Avastin? Is there any way around this? He has Medicare primary plus another secondary. Thank you.

Carli,

So sorry to hear about this complication. Terrifying and stressful... off the charts. I hope things get sorted out.

Maybe the hospital has a social worker who can help? We found at the hospital in Oakland CA and Portland ME that the social worker was the very best contact and problem solver.

Best wishes, hope & peace,

Sarah

mom of Andy 26 dx GBM/PNET 1/09

Carli,

Call the makers of avastin directly.  The company's name is Genentech.  You can find them on the web.  When my husband's insurance co. would not pay for it, they dealt with the ins. co directly and then they ended up providing it for him.They moved fast for us and it wasn't a crisis situation.  Hopefully, you will get good customer service quickly.  They are highly motivated to get their drug out there so they will probably do the leg work for you.  You may have to run the phone maze, but don't give up.

Best wishes,

Jackiekay

I agree with sarah. Have the doc's office get on the phone with insurer...sometimes they just send in request forms and let chips fall where they may. They need to explain his story in full and go from there. Good luck!

I am not sure about Medicare but check again. Avastin was recently approved as a Treatment for recurrent GBM by the FDA. It should be no different than getting approved for Temodar.

I think you're missing her question.  She isn't saying she cannot get avastin for her husband.  She is saying he cannot get it while hospitalized.  They are telling her it is only administered in an outpatient setting.  That is her question. 

Hi, Ieft a response for you on the insurance board.  There are some advocacy organizations that may be able to help you, your State HIICAP program, and the Medicare Rights Center (see my other post for contact info). 

The Medicare Rights Center has done work around medicare drug issues, including access to chemo drugs (I know avastin is not a chemotherapy) and access to drugs while in the hospital.  I would contact both advocacy programs to try to get help. 

There is a medicare coverage center where you can research things, http://www.cms.hhs.gov/center/coverage.asp
If you put avastin in the search box, it pulls up a lot of info.

Guess what... I've just been told that Avastin infusion as inpatient varies by facility. Some places don't do it. So it's not Medicare saying no it's the hospital. I am expecting my husband to receive the drug in a day or two, here at local hospital...then I'll know for sure whether this is true.

I am a RN, who happens to work for a major health insurance company, who happens to have a mom with GBM.  My question to the hospital would be WHY can't it be administered?  I can't think of a reason why insurance would deny coverage (if they would approve it outpatient), because it would most likely be infused by the same hospital anyway, same supply costs, etc.  My thinking is that maybe the nurses on the floor aren't competent to infuse the Avastin.  Does the patient go to this facility for oncology visits?  From a nurse's point of view, I would think that if the patient is stable enough to be taken by wheelchair to the infusion area, then why can't it be given?  If he is stable enough to receive Avastin & is being offered the drug, then why not?  Being that the oncologist is likely seeing the patient while inpatient, he or she may be willing to make this happen.  If not, then WHY not?

From a GBM family member's point of view, I would be on the horn with a hospital case manager to get an explanation. 
I wish you the best.  It's awful to have to be in these situations, I know.  There have been many times when my family has had to dig deep in order to get my mom what she has needed in terms of medical care.  

Jennifer, daughter to Ann (age 58 GBM diagnosed 10/08, taking Avastin)

My Father was administered Avastin on an inpatient basis at Columbia Presbyterian Medical Center. He was living at home with 24/7 live-in support. I transported him every 2 weeks  to NYC for his infusions. He had to stay overnigh - a requirement for reimbursement I was told. I was also advised that Medicare would only pay for it if it was administered on an inpatient basis. This was Nov./Dec. '08. I'm not sure if they changed the reimbursement guidelines. Hope it helps..good luck!

Barbara