December 18, 2008 at 1:51 pm #24195billParticipant
The appeal should address the reason for denial and the specific plan provisions that cover the type of treatment you are seeking. For example, if BCBS denied the PET because it was not “medically necessary”, you should appeal their interpretation of medically necessary (it should be defined in your plan document). Your physician’s office may be able to help you there.
Didn’t someone just post the findings of a study that showed PETs really can help in the diagnosis of his cancer? That may be helpful to include aslo.
I would also get your employer involved (asssuming it is an employer sponsored plan). Chances are you have a “self-insured” plan so the employer is actually the decision maker and the insurance company just an administrator in that case.
Let me know if I can help. Keep fighting. Good luck.
BillDecember 18, 2008 at 2:57 am #24194suzannegmMember
I understand your frustration. BCBS has denied me a PET scan that the interventional radiologist thinks is necessary. Does anybody have a template of an appeal letter I can use. I have NO IDEA how to write one. I have no idea what I’m doing. HELP!November 14, 2008 at 1:27 pm #24193walkMember
Wow, Carol, sorry to hear you are having a tough time.
As far as oncologists, we have seen Dr Paschold once and really liked him. We have a second opinion appointment with Dr. Shen at Baptist.
If you still need the handicapped parking tag, see Charlie’s primary care physician.November 14, 2008 at 1:12 pm #24192carol58Participant
Thanks Lainy. I’m so glad Teddy is getting ready to have Cyberknife.
Hey Marion, no reason, but believe me, I’m going to ask. Same doctor that wouldn’t sign the form for a handicapped sticker for Charlie. He doesn’t want to sign anything or do anything extra. Nice guy, but I don’t understand it. Maybe it’s time for us to go back to Chapel Hill. It’s a 2 hour drive, but might be worth it. I guess Charlie’s tumors fall into the more than 6 cm category since he can’t have Cyberknife. Thanks for finding that out. It’s good information.
Does anyone know of (especially the NC people on here) of any oncologists at Forsyth Hosp. or Wake Forest Baptist Med. Center who give a damn?? Sorry, just slipped out, I’m still so frustrated. Charlie is still eating, doing what he can when he feels like it, definitely not ready to give up. But when your doctor seems to give up and insurance denies, what do you do? I mean it’s possible Charlie could live quite a bit longer with the spheres procedure. He’s in good health except for his darn liver, no mets, good attitude. But if we keep waiting….well we know what will happen. There I go venting again. Thanks.
CarolNovember 14, 2008 at 6:12 am #24191marionsModerator
Today, I had been told that the tumor must be less than 6 cm for cyberknife to be an option. Carol, did the oncologist give a reason as to why he did not want to support you with a letter to the insurance company.November 14, 2008 at 3:10 am #24190lainyParticipant
Carol, I wish had some words of wisdom having just done the fight. I know that most doctors will fight for you so perhaps a change of doctors? I also know that Cyber knife cannot be done to tumors that are too big but I don’t know what that size limit is. And the Insurance company did insist Teddy have radiation first. It did shrink the tumor to the “right” size. I would be ready to hit someone too. I just don’t understand a doctor refusing to write a letter. Maybe someone else can give you some good guidance on here. Its just all so unfair!!!! Vent and rant all you want!November 14, 2008 at 2:33 am #1726carol58Participant
Anybody have a magic wand or a baseball bat to knock some sense into these insurance people?? I AM SO FRUSTRATED! Charlie has had about everything there is to have for this cancer. Blue Cross Illinois has denied the SIRspheres procedure that seems very promising for cc. They are microscopic beads of radiation injected directly into the liver tumors through the femoral artery. Charlie doesn’t have mets yet. We’re in NC, but his insurance is Illinois because he was the Photo Lab Supervisor at our local Walgreen’s before his diagnosis and subsequent disability. Walgreen’s is still paying for Charlie’s insurance until 12/31/08 and then we have to go on Cobra. Dr. Kennedy in Cary is trying. We’re in the appeals process. There’s a guy with the Sirtex company also trying to get them to approve it. In the meantime, Charlie’s taking a lower dose Xeloda oral chemo pills and very uneasy that without more treatment the tumors will grow. It’s not looking good. Our oncologist at Wake Forest Med. Center said he wouldn’t write a support letter for Charlie to the insurance company. We feel like he’s giving up on Charlie. I just don’t get it. I want to hit something!!!!!!!
Thanks for letting me blow some steam off. If anybody knows of anything else we can do to get BC to approve the SIRspheres, please let us know. If it is finally denied, I don’t know what Charlie can do next. The doctor said his tumors are too big for Cyberknife and wrapped around the biliary tree so radiation wouldn’t be good either. (Charlie had 25 radiation treatments this past Jan. after his resection). I’m thinking Tarceva, Nexavar, AZD6244, Avastin? Any other ideas or information is greatly appreciated.
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