CancerCompass message board discussion started by CAgirl on 7/3/2008 http://www.cancercompass.com/message-board/message/all,25704,0.htm Sun, 23 Nov 2008 00:00:00 GMT Sun, 23 Nov 2008 00:00:00 GMT http://backend.userland.com/rss RSS.NET: http://www.rssdotnet.com/ I have had the same health insurance since 1981, they were very generous with me when Thyroid Carcinoma was diagnosed in 1986, paid 100% of partial thyroidectomy, and follow-up with my endocrinologist appointment/labs for 5 years without contest. Then, in 1991 they gently advised me that my Primary Care Physician could take care of monitoring the lab tests. Funny thing though, while the HMO sounded agreeable to me, they apparently told my primary care doctor that it wasn't necessary to take the Tg (Thyroglobulin) or TgAb (Antibodies), only the lab work for T3, T4 and TSH needed to be run, as a 5 year survival means "cure".When finally checked by the original endo, my Thyroglobulin test was 600. Off to emergency high dose Radioactive Iodine ablation I went. Since WBS was not helpful, the Thyroglobulin tests will determine whether I need to have a PET scan to locate any metastases. Now, after less than a year after ablation and two Tg blood tests, the HMO says I don't need to be followed by my endocrinologist anymore, and is denying appointment (with only 3 days notice before my appointment date). What gives? How many of you have had your HMO deny your appointment to your endocrinologist when you are being followed for Follicular Carcinoma recurrence? How did you deal with it? Well, I do know avenues for recourse, but they all take time; any thoughts on a fast solution?Needless to say, I'm upset about this. Yes, I can go pay my endo out of my own pocket, that's not the point; What if I do need a PET scan to find where the metastases is? Plus the posibility even more medical attention to resolve? This HMO interference is out of line. Am I being overly anxious? CAgirl Thu, 03 Jul 2008 00:00:00 GMT I can sympathize with you because my insurance paid for my Thyrogen once and this time it would not pay for one single cent of it.  I even appealed it and got the "letter of necessity" the insurance company required for an appeal.  They still denied it!  I had to charge almost $3,000 so I could get it. I guess they insurance companies can do whatever they please.  If you pay out of pocket to see your endo and he/she decided you needed a PET scan----would your insurance pay for the PET?    Share you situation with your endo--maybe they will work with you.   Good luck.  Tara YaYaTara Fri, 04 Jul 2008 00:00:00 GMT Check out the Women's Health and Cancer Rights Act of 1998.  I don't know for sure that this legislation covers your situation, but it might.  If it does, you can go back to the HMO and tell them you know they are required by law to continue appropriate coverage.  If the WHCRA does cover your situation, and the HMO still denies you, see a lawyer. If the WHCRA doesn't cover your situation, or if you need help interpreting the language, try contacting a cancer patients' rights group, or a patient advocacy group.  An internet search should give you contact information for each.  Stick with your fight - even to the point of becoming a pain to the HMO.  Sometimes the HMO administrator will decide it's easier to cover the service than to deal with a very irate patient. Good luck!  and I hope your health is ok!Tre trehouse60 Fri, 04 Jul 2008 00:00:00 GMT On 7/4/2008 YaYaTara wrote:I can sympathize with you because my insurance paid for my Thyrogen once and this time it would not pay for one single cent of it.  I even appealed it and got the "letter of necessity" the insurance company required for an appeal.  They still denied it!  I had to charge almost $3,000 so I could get it. I guess they insurance companies can do whatever they please.  If you pay out of pocket to see your endo and he/she decided you needed a PET scan----would your insurance pay for the PET?    Share you situation with your endo--maybe they will work with you.   Good luck.  Tara Thanks for answering... Yes, I can appeal by mailing a "letter of necessity" within 180 days and they will respond in 30 days. Yes, I can just pay for my appointment myself (probably only $60 or so), but as you pointed out if he wants to go any further with my care after the HMO has cut him off, I would have to pay for a PET scan myself too if ordered by the endo, otherwise if my primary care doctor ordered it, insurance would have to pay under those circumstances. Now after I've calmed down from reading their letter of "interference", I realize that there are ways to get the denial worked through. Not that it has lowered my blood pressure one bit in this realization. You bring up a interesting comment about the price of your Thyrogen injections. I too, had three thyroid injections prior to RAI. My endo requested approval to administer, my primary care doctor had to give a written approval, and the HMO required it be purchased from Walgreen's in Oxnard, CA. There was some confusion about who was going to administer it -- HMO said to have Walgreen's give the injection. Walgreen's of course, is a pharmacy and said "oh no, we deliver the injections to your Endo and he give's you the injections. In the course of speaking with Yesenia at Walgreen's 805-639-0917, she told me that the injections are sometimes approved, then payment is rejected, so she would call the HMO and confirm payment. Sorry, this is longwinded, but the bottom line is that my 3 injections cost at little over $900 and were paid for by the HMO. A far cry from $3,000. You might want to make a call to find out for yourself, or have a attorney call on your behalf, perhaps you can get some reimbursement. Let me know how this plays out for you. CAgirl CAgirl Fri, 04 Jul 2008 00:00:00 GMT On 7/4/2008 trehouse60 wrote:Check out the Women's Health and Cancer Rights Act of 1998.  I don't know for sure that this legislation covers your situation, but it might.  If it does, you can go back to the HMO and tell them you know they are required by law to continue appropriate coverage.  If the WHCRA does cover your situation, and the HMO still denies you, see a lawyer. If the WHCRA doesn't cover your situation, or if you need help interpreting the language, try contacting a cancer patients' rights group, or a patient advocacy group.  An internet search should give you contact information for each.  Stick with your fight - even to the point of becoming a pain to the HMO.  Sometimes the HMO administrator will decide it's easier to cover the service than to deal with a very irate patient. Good luck!  and I hope your health is ok!Tre Thanks for answering. Good resource, but I suspect that Women's Health & Cancer rights have more to do with breast and ovarian cancers... You're right, the HMO administrator might change denial, this HMO has been in the news lately and highly criticized for turning down patients with a variety of cancers. CAgirl CAgirl Fri, 04 Jul 2008 00:00:00 GMT You have the right to file an emergency appeal and you have to be answered within 48 hours. Have your PCP doctor call and get involved. Also have the PCP fax a letter (get the Nurse Coordinator's name) following your case and fax the letter directly to her. Insurance companies are looking to save every penny, don't let them play with your life. You can also get The Commission of Insurance from your State involved. I am from NYC and HIP Insurance denied almost everything for my husband. I fought them for every thing they denied and won every denial. The doctor from the Insurance Company who reviewed my husbands records for surgery was not a surgeon, or Kidney Specialist, just a Family Doctor, get that. This is who reviewing cases at the HMO, you need to have the Specialist and your Primary Care doctor fight for you. Best of Luck Wilmabc Sat, 05 Jul 2008 00:00:00 GMT I appreciate the information regarding the Thyrogen, CAgirl, since I will no doubt be using it every 6-12 months for the rest of my life. (Also, my father is an attorney--I never thought to involve a letter from an attorney!).  I had to order my own Rx and pay for it before they would mail it to my endo to inject (and of course there is a charge for a nurse to actually stick the needle in my bottom!).   I'll do some research for next time and use that name and phone # you gave me--thank you!  I had to call Medco (my pharmacy through mail order) and then they had me call CuraScript who wouldn't send it until I gave them my charge card #--and it was right at $3,000!!  Someone in there is making some money, huh?  I strongly considered just going hypo for the tracer and then read the message board which brought back memories of not being able to walk upstairs to my bedroom because of weakness---it was like a baseball bat to the temple of my head!  BAM....so I thought "$3,000 isn't much is it?!"  Of course reality hit when I received my Chase bill!  Thank you for your support.  I wish I had answers for you and your dilemma.   I know that I had to jump through hoops for the insurance company to get my PET scan.  They said that to prove I needed a PET scan, I had to have a CT scan to verify that I needed it!!  It ended up costing them more money than if they would have just approved the PET because my doctor needed specifically a PET.  And I don't appreciate the extra radiation my body has to take to qualify for the test I needed in the first place.  I'm the one rambling here.  Sorry!   Let me know what you find out.  The important issue is that we beat this monster!  Tara YaYaTara Sat, 05 Jul 2008 00:00:00 GMT  On 7/3/2008 CAgirl wrote:I have had the same health insurance since 1981, they were very generous with me when Thyroid Carcinoma was diagnosed in 1986, paid 100% of partial thyroidectomy, and follow-up with my endocrinologist appointment/labs for 5 years without contest. Then, in 1991 they gently advised me that my Primary Care Physician could take care of monitoring the lab tests. Funny thing though, while the HMO sounded agreeable to me, they apparently told my primary care doctor that it wasn’t necessary to take the Tg (Thyroglobulin) or TgAb (Antibodies), only the lab work for T3, T4 and TSH needed to be run, as a 5 year survival means "cure".When finally checked by the original endo, my Thyroglobulin test was 600. Off to emergency high dose Radioactive Iodine ablation I went. Since WBS was not helpful, the Thyroglobulin tests will determine whether I need to have a PET scan to locate any metastases. Now, after less than a year after ablation and two Tg blood tests, the HMO says I don’t need to be followed by my endocrinologist anymore, and is denying appointment (with only 3 days notice before my appointment date). What gives? How many of you have had your HMO deny your appointment to your endocrinologist when you are being followed for Follicular Carcinoma recurrence? How did you deal with it? Well, I do know avenues for recourse, but they all take time; any thoughts on a fast solution?Needless to say, I'm upset about this. Yes, I can go pay my endo out of my own pocket, that's not the point; What if I do need a PET scan to find where the metastases is? Plus the posibility even more medical attention to resolve? This HMO interference is out of line. Am I being overly anxious?Your HMO is out of line. Once you are in remission you will still need to be checked at least yearly for the rest of your life according to my doctor.  I have not had a problem with my group insurance at work, except for my prescription plan CxxxMark.  They will not cover the Thyrogen shots needed for the stimulated thyrogolbulin test ~$1700-2000 for two injections.  I need to have my doctor educate them and file an appeal. I have been having my doctors office bill it as a medical procedure.  I pay AETNA specialty pharmacy and they ship the Thyrogen to the doctors office. I pay the medical co-pay directly to AETNA.  My doctor hinted that I may have a problem getting my insurance to pay for a PET scan if needed later, unless everything else is tried and it is a last resort. On my second re-occurence (elevated thyroglobulin) no tumors were found. MRI of neck, CT of head and chest. Rad uptake whole body scan.  I will find out in Aug 08 if the second ablation worked by a non stimulated thyroglobulin test and followup late in the year with a stimulated test.  ThyCanDave Sun, 06 Jul 2008 00:00:00 GMT  On 7/6/2008 ThyCanDave wrote: On 7/3/2008 CAgirl wrote:I have had the same health insurance since 1981, they were very generous with me when Thyroid Carcinoma was diagnosed in 1986, paid 100% of partial thyroidectomy, and follow-up with my endocrinologist appointment/labs for 5 years without contest. Then, in 1991 they gently advised me that my Primary Care Physician could take care of monitoring the lab tests. Funny thing though, while the HMO sounded agreeable to me, they apparently told my primary care doctor that it wasn’t necessary to take the Tg (Thyroglobulin) or TgAb (Antibodies), only the lab work for T3, T4 and TSH needed to be run, as a 5 year survival means "cure".When finally checked by the original endo, my Thyroglobulin test was 600. Off to emergency high dose Radioactive Iodine ablation I went. Since WBS was not helpful, the Thyroglobulin tests will determine whether I need to have a PET scan to locate any metastases. Now, after less than a year after ablation and two Tg blood tests, the HMO says I don’t need to be followed by my endocrinologist anymore, and is denying appointment (with only 3 days notice before my appointment date). What gives? How many of you have had your HMO deny your appointment to your endocrinologist when you are being followed for Follicular Carcinoma recurrence? How did you deal with it? Well, I do know avenues for recourse, but they all take time; any thoughts on a fast solution?Needless to say, I'm upset about this. Yes, I can go pay my endo out of my own pocket, that's not the point; What if I do need a PET scan to find where the metastases is? Plus the posibility even more medical attention to resolve? This HMO interference is out of line. Am I being overly anxious?Your HMO is out of line. Once you are in remission you will still need to be checked at least yearly for the rest of your life according to my doctor.  I have not had a problem with my group insurance at work, except for my prescription plan CxxxMark.  They will not cover the Thyrogen shots needed for the stimulated thyrogolbulin test ~$1700-2000 for two injections.  I need to have my doctor educate them and file an appeal. I have been having my doctors office bill it as a medical procedure.  I pay AETNA specialty pharmacy and they ship the Thyrogen to the doctors office. I pay the medical co-pay directly to AETNA.  My doctor hinted that I may have a problem getting my insurance to pay for a PET scan if needed later, unless everything else is tried and it is a last resort. On my second re-occurence (elevated thyroglobulin) no tumors were found. MRI of neck, CT of head and chest. Rad uptake whole body scan.  I will find out in Aug 08 if the second ablation worked by a non stimulated thyroglobulin test and followup late in the year with a stimulated test.  My BC/BS have denied my Thyrogen injections (3) and I had to use my VISA to pay the $3,000!  Don't know what I'm going to do with having to do it at least once a year.  My doctor wrote a 'letter of necessity' which they asked for and still denied it.  I have another letter from my endo that I will enclose in my appeal to the insurance company.  Hopefully they paid for my PET scan---but who knows.  Let us know how you are doing.  Tara   YaYaTara Sat, 12 Jul 2008 00:00:00 GMT