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Topic: Blue Cross denies Oncotype Dx

Forum: Employment, Insurance, and Other Financial Issues —

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Posted on: Aug 30, 2017 06:39PM

CA-Sunshine wrote:

Hello BCO family,

Just wondering if any one has experience this.. Today l was informed my pre auth for oncotype was denial because l have DCIS.. l was dx on 6/12 with 2 tumors. TUMOR (A)2:30 DCIS and tumor (B) 3:30 with IDC additionally l have micrometasis to one lymph nodes per my surgical path report. I am er/pr + her - stage llB grade 3. I sent a letter asking that they please reevaluate my case as this test is medically necessary and not investigational for tx of DCIS as they stated for the reason to deny the claim.. Can some please advise what l should do

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Aug 30, 2017 06:51PM pupmom wrote:

CA-Sunshine, you are NOT just DCIS if you have invasion. According to your post, you are IDC with one positive node. (DCIS is always considered just secondary to invasive cancer. I, and many others have had it in our pathology reports.) There's no reason why insurance should deny the Oncotype test. Maybe you, or your MO, misrepresented your diagnosis. If so you should be able to correct this easily.

Life is what happens while we're making other plans. Dx 10/18/2011, IDC, Right, 1cm, Stage IIA, Grade 1, 2/21 nodes, ER+/PR+, HER2-
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Aug 30, 2017 08:22PM edwards750 wrote:

I was thinking the same thing pupmom. Doesn't make sense.

CASunshine - I have BC and they actually approved the Oncotype test initially and then declined it. Genomic Labs who conducted my Oncotype test said they do that all the time. They were prepared for the appeal. Apparently it was successful because that was the last I heard about it. I was IDC, Stage 1b, Grade 1. I had a micromet in my SN but they considered that node-negative.

Thank God for the test. I dodged chemo because my score was 11. My ONC ordered the test and my BS called with the results. I don't understand why the insurance companies don't factor in that chemo is so expensive so they save $. Regardless I'm just blessed to have had Rads instead.

I agree with pupmom too and I would refile.

Diane

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Aug 30, 2017 08:25PM - edited Aug 30, 2017 08:27PM by CA-Sunshine

Hi Pupmom and Edwards

I agree with everything you said.. l faxed the pre auth dept a letter disputing their decision as l know my treatment will be tailored toward treating my IDC and not my DCIS tumor. I also attached a copy of my path report which shows both IDC and DCIS and micromets to my node

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Aug 30, 2017 08:27PM letsgogolf wrote:

Blue Cross approved the Oncotype DX for me. I have the bronze plan. I have IDC with lobular features, Stage 1B, Grade 1 with 1 micromet. My score was 3.

Oncotype DX = 3. IDC with Lobular Features. Sentinel Node had Micrometastases - Estrogen 100%, Progesterone 99.89%, Ki67= 3.3% Dx 2/14/2017, IDC, Left, 1cm, Stage IB, Grade 1, 0/8 nodes, ER+/PR+, HER2- Surgery 2/26/2017 Lumpectomy: Left Radiation Therapy 4/5/2017 Whole-breast: Lymph nodes Hormonal Therapy 5/31/2017 Arimidex (anastrozole)
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Aug 30, 2017 08:45PM CA-Sunshine wrote:

l clearly do not know why they would deny me. I am hoping that overlooked something on my report because the supporting evidence is there. I am so frustrated l do not know what to do.. l have an appt to see MO on 9/12 so l would like my results available to be in a better position in advocating for myself in treatment planning..

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Aug 30, 2017 08:48PM farmerlucy wrote:

Have you talked to the oncotype people? Sounds like an error to me. Maybe they can put your test on the fast track.

Dx at 51 after a preventive mx that wasn't. Oncotype dx 3. 3D tattoos from Vinnie! PTSD?? You are not alone! Surgery 2/21/2012 Prophylactic mastectomy; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Dx 2/24/2012, IDC, Right, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2- (FISH) Surgery 3/11/2012 Lymph node removal: Sentinel Surgery 7/22/2012 Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Hormonal Therapy 4/10/2013 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 4/14/2015 Prophylactic ovary removal
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Aug 30, 2017 09:37PM CA-Sunshine wrote:

No l have not spoken with reps at genomics again after l was told they were still waiting auth from BC. l will call them in the morning to see what assistance they can give in getting BC to pay. The specimen has been tested but they will not release the results..

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Aug 30, 2017 09:47PM Falconer wrote:

CA- Sunshine, I'm so sorry you have to deal with this. Dealing with this disease is stressful enough. I have a very similar pathology as you. I waited weeks and weeks to get my onco score back- my MO said there was a mistake in the insurance. I too have Blue Cross. He never said what it was, but perhaps they denied the claim because there was DCIS in the paperwork. I've been thinking about starting a group protest against Blue Cross- standing outside their headquarters with our headscarves and radiated breasts and mouth sores and mastectomy scars and tissue expanders- just throwing it all in their corporate faces so they can see the reason why we need their damn approval.
Strong is the new strong. Dx at 45. Onco 16. Monthly Lupron shots Nov. 2016-December 2017 Dx 7/2016, IDC, Left, 1cm, Stage IB, Grade 2, 0/3 nodes, ER+/PR+, HER2- Dx 7/2016, DCIS, Left, 5cm, Stage 0, Grade 3, 0/3 nodes, ER+/PR+, HER2- Surgery 5/30/2017 Reconstruction (left): DIEP flap Surgery Lymph node removal: Sentinel; Mastectomy: Left Radiation Therapy Whole-breast: Breast, Lymph nodes, Chest wall Hormonal Therapy Aromasin (exemestane), Femara (letrozole), Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Aug 30, 2017 10:14PM CA-Sunshine wrote:

Their actions are so unfair. In the letter l faxed them l stated that their unjust decision could possibly affect my mortality by not authorizing the claim. So sad
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Aug 31, 2017 06:26AM pupmom wrote:

Just want to add that, like edwards, I also dodged chemo, even with 2 positive nodes, based on my Oncotype score of 14. As I mentioned I also had DCIS present, but that is barely mentioned as part of my dx. It really is irrelevant. BC/BS of Kansas approved the test. For those who are ER+, and have 3 or less nodes it is completely standard practice. In my opinion you need to get your doctors to strongly petition BC for the test, because this is outrageous. No reputable doctor would want to give someone chemo if it wouldn't benefit them.

Life is what happens while we're making other plans. Dx 10/18/2011, IDC, Right, 1cm, Stage IIA, Grade 1, 2/21 nodes, ER+/PR+, HER2-
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Aug 31, 2017 07:46AM letsgogolf wrote:

I think many of us had DCIS in our pathology report. I know that I did. Isn't that where the IDC escaped from? I believe it is usually there but possibly not on the report because they don't always find it and remove it during the surgery. While I was in surgery the pathologist told the surgeon to remove more tissue from one margin and that is when the DCIS was discovered. Nobody mentioned this DCIS to me. I found it buried in my report. It had the same properties as my tumor.

Oncotype DX = 3. IDC with Lobular Features. Sentinel Node had Micrometastases - Estrogen 100%, Progesterone 99.89%, Ki67= 3.3% Dx 2/14/2017, IDC, Left, 1cm, Stage IB, Grade 1, 0/8 nodes, ER+/PR+, HER2- Surgery 2/26/2017 Lumpectomy: Left Radiation Therapy 4/5/2017 Whole-breast: Lymph nodes Hormonal Therapy 5/31/2017 Arimidex (anastrozole)
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Aug 31, 2017 08:01AM SummerAngel wrote:

I would think that the denial was a mistake. I had BCBS when I was diagnosed and had no trouble getting the test covered.

Age at dx: 45. Oncotype, left-side tumor: 9. Right side had multifocal IDC and "extensive" LCIS. Isolated tumor cells in 1 right-side node. Dx 4/3/2015, IDC, Left, 2cm, Stage IIA, Grade 1, 0/3 nodes, ER+/PR+, HER2- (FISH) Dx 4/27/2015, IDC, Right, 1cm, Grade 1, 0/2 nodes, ER+/PR+, HER2- (FISH) Surgery 6/1/2015 Lymph node removal: Sentinel; Mastectomy: Left, Right Surgery 6/1/2015 Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Surgery 8/28/2015 Reconstruction (left): Fat grafting, Silicone implant; Reconstruction (right): Fat grafting, Silicone implant Surgery 12/4/2015 Reconstruction (left): Fat grafting, Nipple reconstruction; Reconstruction (right): Fat grafting, Nipple reconstruction
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Aug 31, 2017 09:26AM cive wrote:

Whoever submitted the original request may have coded it wrong.  Yeah, miscoding insurance stuff can cause a useless denial and it happens not infrequently.  We almost need to be insurance experts.

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Aug 31, 2017 10:39AM CA-Sunshine wrote:

So l just got off the phone with the rep at Genomics, she stated their billing dept has already resubmitted a claims to Blue Cross. So praying it is approved this time and my results will be available at my MO appt on 9/12. This is making my head hurt on top of today being 33 yrs ago today my mom lost her battle to BC, now here l am in the same fight that she lost. I will be spending my day doing a bone scan, CT and bloodwork. Oh what a day

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Aug 31, 2017 01:31PM edwards750 wrote:

Remember Genomics is all too familiar to with rejections especially by BC. They know how to resubmit to get themto approve.

So sorry about your Mom. Mine had BC too and passed away 10 years ago but not from BC. Both my sister and I have BC. I am 6 years out and she is almost 5.

I had a lumpectomy+Rads. She had a MX and takes Arimidex. She didn't have to have chemo or Rads. We are both doing well thankfully.

You will get through this. We are all here to help. Keep the faith.

Diane

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Aug 31, 2017 01:40PM bevin wrote:

your oncologist should also call them and request a review. Oncotype is now standard of care.

Age 45, Oncotype 11, Primary Tumor 2.1 cm, smaller satellite tumor nearby Dx 8/8/2010, IDC, 2cm, Stage II, Grade 3, 0/5 nodes, ER+/PR+, HER2- Surgery 8/10/2010 Lumpectomy: Right; Lymph node removal: Right, Sentinel Radiation Therapy 10/10/2010 Breast
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Aug 31, 2017 04:15PM Falconer wrote:

CASunshine, I am sorry to hear about your mom's passing to this awful disease. Much has changed in 33 years-for the better- so keep hope there.

I did recall after thinking about it, that my MO also did the legwork with BCBS, even though he didn't tell me that's quite what was happening.
Strong is the new strong. Dx at 45. Onco 16. Monthly Lupron shots Nov. 2016-December 2017 Dx 7/2016, IDC, Left, 1cm, Stage IB, Grade 2, 0/3 nodes, ER+/PR+, HER2- Dx 7/2016, DCIS, Left, 5cm, Stage 0, Grade 3, 0/3 nodes, ER+/PR+, HER2- Surgery 5/30/2017 Reconstruction (left): DIEP flap Surgery Lymph node removal: Sentinel; Mastectomy: Left Radiation Therapy Whole-breast: Breast, Lymph nodes, Chest wall Hormonal Therapy Aromasin (exemestane), Femara (letrozole), Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone)
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Sep 17, 2017 10:51PM swg wrote:

UGH I hate every BC insurance company..I have Independence Blue Cross, and they threw me off their plan last year for no reason ( I have ACA insurance). I got back on in open enrollment (in PA, they're our only choice on the exchange). I'm scared to death they will do the same thing to me while I'm in this cancer fight and I will end up with no coverage just when I need it for treatment!!

Dx 9/11/17. IDC grade 2, stage 1. 1.2cm. in right breast. ER+/PR+, HER2- 2nd tumor in right breast found 10/22/17. Dx 9/11/2017, IDC, Right, 1cm, Stage IA, Grade 2, 0/3 nodes, ER+/PR+, HER2- (IHC) Dx 10/23/2017, DCIS/IDC, Right, <1cm, Stage IA, Grade 1, 0/3 nodes, ER+/PR+, HER2- Surgery 11/28/2017 Mastectomy; Reconstruction (right): Tissue expander placement
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Nov 30, 2018 09:35PM Geneie2 wrote:

I was also denied twice. Initially I was told when I called for prior approval that I was covered as long as my referring doc went through correct protocol for pre-approval. Oncotype people said no need. They have a contract with my BC BS HIGHMARK insurance. Turns out we were both incorrectly informed. If I had invasive I would have been covered, but, is considered experimental with DCIS. I am looking at a bill for $4,700. I told everyone to make sure I have prior approval before they do the test. Everyone let me down. I no longer trust anything my Insurance tells me. Oncotype people gave my referring doc wrong information regarding my coverage. I CLEARLY communicated I Ihad DCIS, and was inquiring about coverage of DCIS ONCOTYPE .It is crazy because the cancer has not left the duct I am not covered. If a cancer cell had escaped, then I would be covered. How can this be considered “experimental’? It not logical.

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Dec 1, 2018 09:42AM carmstr835 wrote:

I was covered for the onca score, but not mammaprint. I have an over $8,000 bill from them. I have bilaterl cancer so there were 2 tumors to send in. I have blue cross PPO.

Dx 3/1/2017, DCIS/IDC, Both breasts, 1cm, Stage IIB, Grade 2, 2/17 nodes, ER+/PR-, HER2+ (FISH) Hormonal Therapy 3/21/2017 Arimidex (anastrozole) Surgery 3/26/2017 Lymph node removal: Right, Sentinel, Underarm/Axillary; Mastectomy: Left, Right; Reconstruction (left): DIEP flap; Reconstruction (right): DIEP flap Chemotherapy 5/17/2017 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Targeted Therapy 6/26/2017 Herceptin (trastuzumab) Chemotherapy 6/27/2017 Carboplatin (Paraplatin), Taxotere (docetaxel) Targeted Therapy 6/27/2017 Perjeta (pertuzumab) Radiation Therapy 9/10/2017 Breast, Lymph nodes, Chest wall Surgery 7/9/2018 Reconstruction (left): DIEP flap; Reconstruction (right): DIEP flap Surgery 10/15/2018 Reconstruction (left): Fat grafting; Reconstruction (right): Fat grafting Targeted Therapy Nerlynx
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Dec 1, 2018 06:10PM MLAnne wrote:

bevin~ If Oncotype is now considered 'standard of care' as you put it and Genomics is the only lab that provides it, can an insurance company reject coverage for being Out Of Network? There wouldn't be a comparable in network provider, right? Or am I grasping at straws here?

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Dec 2, 2018 06:02PM edwards750 wrote:

I don’t understand why Mammaprint isn’t covered. I also don’t get why BC rejected your claim because it was OON. Typically you are responsible for the greater portion of the bill if it is OON but my experience has been they paid something.

Also I was told by a BC rep that the doctor can appeal the denial for you. We had an experience with an OON claim. The doctor fumbled the ball by not appealing. It took multiple phone calls and a written appeal to win our case but we did. Needless to say that doctor was history.

Be persistent. A lady who had worked in a doctors office for years said the squeaky wheel definitely gets the grease. There’s a lot of money at stake here.

Diane


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