Sir Spheres And Insurance Coverage

Hi everyone, Can anyone tell me if they have had SIR spheres and whether the insurance co. paid for this procedure? My son is Stage iv with mets to liver and this was suggested by a doctor in Pittsburgh but United Health Care said that the hospital is out of network and won't reimburse. I am now looking for a place in and around Boston where United Health Care would cover the expenses. United Health Care is no help in providing this info and does not even know what the procedure is!! Very frustrating and we were all set up to visit Pittsburgh on Monday and see a doctor who would run tests and do the SIRT. Any help will be appreciated especially in the dealing with the insurance company as to how to proceed. Very expensive procedure but this is the last hope right now because all chemo has failed. Thanks,Diana (Shawn's Mom)

I am also a Stage IV survivor who went out of state.  My insurance company initially didn't cover anything.  I had the procedure anyway.  The other state paid for 60% of my health care through their community cares program.  I eventually wrote letters to my insurance company and they coverered almost all of it.

It is my belief that most insurance companies assume people will give up, and therefore they can make a lot of money because most people won't pursue incorrect billing further.   

After two and a half years of writing letters and talking to my insurance company, (with the exception of out of pocket) I only paid $800 above.  However, since 60% was paid by the other state, I paid less than my out of pocket.  That was for my first years treatment.

Last year I had no problems, but in 2006, the insurance company is saying my Dr.'s have filled out the paperwork inproperly.  I'm having them resubmitt for the $1,200 over my out of pocket. 

I know it's hard to keep on top of, your bills when you're already stressed from the illness.  I'm just thankful I was well enough to return to work, and write a lot of letters of complaint to my insurance company, and turn in a lot of paperwork to get it paid.  

Sometimes you can have your Doctors work with your insurance company to become part of the plan.  Please don't take this all on yourself.  Ask friends and relatives to help you with all the paperwork.

I googled medical expense report, and it should me several excel templates I could use to keep track of my bills.  This helped keep me organized, especially when you consider I have no clue how to make an excell program.

 Good luck.

 

 

Diana - how old is your son? My son, Jonathan, was diagnosed with Stage IV colon cancer in 2003 at age 19. It's been a nightmarish 4 years...and yet an odyssey of sorts. I've met a young man (my son with colon cancer) that I would have never known (the same son, if he had not had cancer) if cancer had never come our way.

Is he in college? Is he dependent on you for more than 50% of his income? With Stage IV colon cancer, he is considered disabled (terminal diagnosis) and may actually qualify for Medicaid and/or Medicare and/or Social Security benefits.

Bottom line, I'm not sure what procedure you're referring to...but appeal to United Health Care and ask for help from the specialty clinic you are going to. If considered a "Center of Excellence" and they provide a service not available in your area, there may be a way around that clause with United. Bottom line..go for it...you may pay $50.00 per month for the rest of his life to get the bill paid...but go for it if you think it's the right path.

Let me hear from you.

Betty

Hi everyone, I'm back.  Shwn is 30 years old.  I've been busy consulting with everyone from different hospitals around the area.  SIR spheres at Mass. general hospital and chemoembolizaiton at Lahey clinic.  I'm still not sure what is covered and what is not; but I can't worry about that any longer.  We will do what we have to do to help my son. Went to Lahey yesterday and met with Dr. Pomfret about RFA.  Not an option but suggested we see Dr. Keith Stuart about chemoembolization.  Window of opportunity is getting shorter and we will make a decision probably before Christmas as to what procedure we will have done.  Bills are piling up and we will probably spend a day on the phone talking to United Health Care.  Let you know what happens and enjoy your holidays with your families. I don't know what I would do if I didn't have all you to help me.  thanks and Happy holidays!  Diana

I have had 2 series of sirt for my stage 4 liver mets. My insurance has always paid in full. Cherie Brown

Hi!  I, too, have stage IV colon cancer.  I had innumerable tumors in both lobes of my liver.  They seemed to be advancing every day and there were literally no other options. My physician had suggested hospice when a friend told me about the procedure.  I have had 65% reduction in tumors and complete stability in the liver ever since (Jan, 2005).  I'm alive today because of sir-spheres.  My insurance denied the procedure twice even with mediation.  We were lucky that my husband's company changed insurance and I was able to receive the procedure with that change. Sirtex has a department that will help work with your insurance company and I'd be happy to put you in touch with the correct person if you'd like to contact me off-list.  Don't give up on the process.  It can be very frustrating sometimes but I can tell you that my experience was very much worth the hassle.

 Good luck!! 

Hi, I am a stage IV colon cancer with mets to my liver. I also have United Healthcare. My experience with United has been very frustrating. I contacted them before I sought a second opinion (and later surgery) at Mayo and they said it would be covered. I recorded the conversations. Later they denied the claim. (The whole story would take pages and pages to describe, I am abbreviating this.)

I had to go to their board of appeals to get my claim approved and paid. It was a harrowing experience. My husband spent 6 days in our home (unpaid time off work) on the phone with Mayo, United, my company's benefits center, United Board members, etc. etc.

United eventually paid up. Don't take no for an answer from them. Keep pushing them to pay for the treatments your son needs. Record the conversations. Just because a treatment or hospital is not "in your plan" doesn't mean they can't pay for it. They deny the claim and see if you will fight it. Good luck.

Hi everyone,

Shawn is going for a chemoembolization on wednesday. Dr. Geller from Pittsburgh suggested that we visit the Liver team at Lahey and they came up with this option.  We are still considering SIRT but are saving that in case we need it. I still don't know if insurance will cover this either; but we are not stopping any treatments from now on because of this.  We will fight United Health Care if needed.  All of your help was a deciding factor for us knowing that there are options in fighting the insurance company.  Thanks to everyone for your suggestions and support.  Shawn has a 50/50 shot that this will work.  Mass. General has also offered to help us if needed for the SIRT.  We have met a lot of kind and caring people in the last year a a half; and I'm glad that I have participated in cancercompass.  It is truly the best venue for me.  I will let you know within the next 2 weeks how everything went with Shawn's procedure.  I just want to tell everyone not to give up.  New treatments and old ones are available and keep moving around doctor to doctor until you get one that thinks "out of the box".  Diana

Find yourself a health advocacy firms like:  Patient Advocate Foundation (nonprofit) or Health Advocates, Inc (for profit). They will fight for you and your son over this issue. I will be going through this with my wife. Because her liver cancer not hcc and the primary, we will have to battle with the insurance company over the bill. Don't let this stop you!! These firms whether for profit or not have a good track record at stand up for you. Remember: "Never give out, never give in, and neve give up." Just because they are bigger than you doesn't mean you don't have rights.

 

 

On 12/28/2006 Suzanne-yes wrote:

Hi!  I, too, have stage IV colon cancer.  I had innumerable tumors in both lobes of my liver.  They seemed to be advancing every day and there were literally no other options. My physician had suggested hospice when a friend told me about the procedure.  I have had 65% reduction in tumors and complete stability in the liver ever since (Jan, 2005).  I'm alive today because of sir-spheres.  My insurance denied the procedure twice even with mediation.  We were lucky that my husband's company changed insurance and I was able to receive the procedure with that change. Sirtex has a department that will help work with your insurance company and I'd be happy to put you in touch with the correct person if you'd like to contact me off-list.  Don't give up on the process.  It can be very frustrating sometimes but I can tell you that my experience was very much worth the hassle.

 Good luck!!