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Topic: Fighting Anthem/Blue Cross

Forum: Employment, Insurance, and Other Financial Issues —

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Posted on: May 7, 2019 05:40PM

kitkit wrote:

Insurance driving me nuts!

I have Anthem Blue Cross PPO. I have lymph node metastasis of lobular carcinoma in axillary and chest nodes plus I had met in T6. My UCLA doctors recommended stereotactic radiotherapy - one blast - to T6. I had it done two weeks ago and pain is gone. I'm also on Ibrance and Letrozole.

Insurance says even after appeals from dr that they won't pay for my targeted radiation to back because their guidelines say I must have failed first at another radiation. Crazy! Why not have the most targeted and efficient...and also less cost to them if I only have one time rather than a dozen.

Any ideas, sisters? Two doctors have sent appeals, and then requested another review (denied, also). Has anyone gotten this type of decision reversed?

kitkit
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May 7, 2019 06:01PM DebAL wrote:

kitkit, I fought this insurance company for a completely different reason but maybe my experience can help you with your next step.

First, plan on being on the phone for awhile. Call and escalate up until YOU can get your hands on those guidelines...read, try to find a loophole, and write an appeal letter yourself.

GET THIS.. was told that when the first appeal goes thru that the physician that makes the decision can be ANY physician. Like my oncologist asking for approval from an OBGYN lol!!! Are you kidding me?? Once it is escalated up , a physician from the same service line must review it. Only then did an oncologist review my claim and it was approved. (This was after my oncologist was denied in her appeal. )

Drs offices cannot get those guidelines for you. But you can, it's your right. Once you read them there may be an angle that you can make the focus in your letter.

It is time consuming and the last thing you want to be doing when you arent feeling well. But you may have luck.

I'm sorry you are going through this and although our situations are different I thought maybe my experience would help you.


Dx 1/22/2018, IDC, Left, <1cm, Stage IA, Grade 1, 0/3 nodes, ER+/PR-, HER2- (IHC) Surgery 2/12/2018 Mastectomy: Left, Right Surgery 2/12/2018 Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Chemotherapy 4/2/2018 Cytoxan (cyclophosphamide), Taxotere (docetaxel) Hormonal Therapy 6/14/2018 Arimidex (anastrozole) Surgery 8/9/2018 Reconstruction (left): Fat grafting, Silicone implant; Reconstruction (right): Fat grafting, Silicone implant Surgery 12/20/2018 Reconstruction (left): Fat grafting; Reconstruction (right): Fat grafting Surgery
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May 8, 2019 04:56AM Falconer wrote:

I am so sorry you’re in this awful situation with the insurance company. The dx is stressful enough and their heartlessness worse...

I had a major shift when I received the number of my local negotiator from a colleague. I’m a teacher and we are part of a health insurance collective throughblue cross blue shield. I contacted him and shared all of my documentation. He called the insurance company and the next day it was settled.

Good luck to you. Holding you in the light.

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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May 8, 2019 12:04PM kitkit wrote:

Thank you for your responses! My first reviewer was an allergist! The second was a trauma surgeon! I don't have evidence that any radiation oncologist has done a review. i am a very persistent person and am continuing to go up the chain. I am working on several parallel angles at the same time and will report back if anything works!

Take care everyone.

kitkit
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May 8, 2019 02:12PM sbelizabeth wrote:

Kitkit, Falconer has a good suggestion. Where do you get your health insurance? An employer? Call their human resources benefit coordinator and explain what's going on, and ask for help negotiating with Anthem. And consider calling California's Insurance Commissioner to file a complaint. This SO pisses me off.

http://www.insurance.ca.gov/01-consumers/101-help/

pinkribbonandwheels.wordpress.... Dx 10/20/2011, IDC/IBC, Left, 1cm, Stage IIIA, Grade 2, 6/28 nodes, ER+/PR+, HER2- Chemotherapy 12/15/2011 Adriamycin (doxorubicin), Cytoxan (cyclophosphamide), Taxotere (docetaxel) Surgery 4/18/2012 Mastectomy: Left Radiation Therapy 5/21/2012 Breast, Lymph nodes Hormonal Therapy 7/19/2012 Femara (letrozole) Surgery 4/15/2013 Reconstruction (left): DIEP flap; Reconstruction (right): DIEP flap
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May 9, 2019 04:54PM edwards750 wrote:

Appeals do work sometimes. I appealed a claim that was classified OON so it would have cost my DH and I over $5k. The hospital(OON) that did his test was the only one in town who could do it so I appealed to BC/BS and won the appeal. Had the neurologist done her job it would have been handled ahead of time. She didn’t so it wasn’t.

A friend’s husband appealed a denial for coverage 3x before he got the test approved. Squeaky wheel gets the grease. Be patient and persistent.

Diane

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May 10, 2019 11:39AM kitkit wrote:

Thank you,

I intend to be persistent. Anthem says my next step is to request all the paperwork they've considered. I've done it. They say it won't be sent to me until early June. In this day and age we all know that it could be delivered to be instantly if they wanted to. Perhaps they've figured out that the delay will cause some people to give up. I've got it calendared.

K

kitkit
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May 12, 2019 09:13PM edwards750 wrote:

KitKit - BC/BS told my DH and I it would be 30-60 days before our appeal was decided. It took 2 weeks.

Diane

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Jul 2, 2019 11:53AM kitkit wrote:

I won my Anthem appeal!!!

Finally they sent my info to an independent specialist who was a board-certified radiation oncologist. He agreed that the one-time stereotactic radiation to my one T6 met was medically necessary. Anthem kept saying I had to fail first at an entire series of radiation.

Previously I had two appeals denied by Insurance department hacks; one was a trauma surgeon, the other an allergist. I am convinced that they wanted me to give up. The request for independent review takes more time as I had to attach research papers justifying my treatment. The independent reviewer cited even more research supporting my position in a lengthy two page analysis.

What I have learned is to do the extra work and get to an independent reviewer who is in the correct field for review. That made the entire difference.

Good luck to all in my situation

kitkit
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Jul 2, 2019 12:21PM kber wrote:

Congratulations! Yes they do count on you giving up. It's part of their cost management / profit model.

When I was diagnosed, my first call was to my health advocate. The company she works for is actually independent of the insurance company (Aetna in my case) and her job is to help me navigate the insurance complexities that come with a diagnosis like cancer. Well, I drew the lucky straw because my advocate is a bull dog who put the fear of god into them! She's a nurse practitioner experienced in oncology care and from the get go, when we were trying to get a PET scan approved so I could start treatment, she had a take no prisoners approach! She saved me hours of time and more stress that I can imagine.

I've become a true believer - anyone facing a complex or serious illness should find out if they have a advocate associated with their plan and make that person one of their first calls!

Dx 11/2018, IDC, Left, 5cm, Stage IIB, ER-/PR-, HER2- Chemotherapy 12/7/2018 Adriamycin (doxorubicin), Carboplatin (Paraplatin), Cytoxan (cyclophosphamide), Taxol (paclitaxel) Surgery 5/28/2019 Mastectomy: Left; Prophylactic mastectomy: Right Radiation Therapy 7/17/2019 Whole-breast: Breast, Lymph nodes, Chest wall
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Jul 2, 2019 06:50PM edwards750 wrote:

Way to go both of you ladies. Taking on the insurance companies is no easy task. My husband and appealed a $5000 charge BC/BS denied because the procedure was OON. My husband had to have the procedure and the hospital where it was done was OON. It was the only facility in town that did the procedure. I wrote the appeal and we won. It took some doing but was worth it. The thing is it could have all been avoided but my husband’s doctor at the time fumbled the ball because all she had to do was request an exception with BC/BS which she failed to do. Most incompetent doctor’s office we have ever dealt with.

Also a friend’s husband appealed to the insurance company 3 times before they won their case. Persistence pays off. A friend who works for doctors said you can win if you are persistent. She’s seen it happen many times.

Diane

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