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Topic: I won! Oncotype Appeal

Forum: Waiting for Test Results —

For members not diagnosed with breast cancer, but waiting for test results:  Biopsy, mammogram, ultrasound, or other screening tests. Waiting is VERY difficult but remember...

"Worry does not empty tomorrow of its sorrow. It empties today of its strength." -- Corrie Ten Boom

Posted on: Nov 27, 2007 03:42PM - edited Nov 27, 2007 03:42PM by malucho1

malucho1 wrote:

My insurance (blue shield HMO) denied coverage of my Oncotype DX in July 2006. The nice people at Genomic Health went through all three appeals with me. We were denied each time.

Finally, we came to the last and final appeal before the State of California Health Board. My insurance just called to tell me: I WON THE APPEAL! That was 16 months of fighting to get this thing covered.


Dx 5/17/2006, IDC, Stage I, Grade 2, 0/3 nodes, ER+/PR+, HER2-
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Nov 27, 2007 04:17PM lvtwoqlt wrote:

congrats on winning the appeal. sometimes we have to keep pressing to get what we need. I am in the middle of appealing the PS use of AlloDerm during my reconstruction. I am at the third level.

Sheila

Women are like tea bags, we don't know how strong we are until we were thrown into hot water. Eleanore Roosevelt Diagnosed ADH Feb 2005, ADH Sept 2006 Surgery 2/11/2005 Lumpectomy: Left Surgery 9/9/2006 Lumpectomy: Right Hormonal Therapy 10/11/2006 Dx 4/27/2007, DCIS, Stage 0, Grade 1, 0/7 nodes Surgery 5/31/2007 Mastectomy: Left, Right
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Nov 27, 2007 04:23PM - edited Mar 19, 2008 01:19PM by TenderIsOurMight



You did us all a great service by continuing for your right. All the way to the California State Health Board! I am so very proud of you. Individually you have paved the road for other women and men to also be given cutting edge prognostic decision making tools.

Have a party. Call the newspapers. Let the community know in some way, perhaps through the local ACS, or breast cancer support groups, or hospital.

Congratulations! A tremendous individual win, and a great step forward for all with BC!
Tender

It cannot be emphasized too strongly that treatment of each patient is a highly individualized matter. (FDA-approved labeling for warfarin (Coumadin) NDA 9-218/5-105)
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Nov 28, 2007 01:00AM JoelKM wrote:

Congratulations!

It is just insane that they wouln't pay for this. Even if you take the human aspect out of the equation, don't they realize that OncotypeDX could save them money in the long run? If I ran the zoo, that HMO case manager would be fired. 

Spouse Dx 4/07 3.5cm IDC, Stage 2,Grade 3, ER/PR+, HER-2 neg, 3 nodes +, neoajuvent chemo DD AC-T resected 9/07
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Nov 28, 2007 06:21AM JapanLynn wrote:

Woohoo!  Congrats!  I think insurance companies are a necessary evil, and I'm so happy that you persevered and got the coverage you deserve. 

A celebration is in order!

Lynn

Dx 7/30/2007, IDC, 1cm, Stage IA, Grade 2, 0/2 nodes, ER+/PR+, HER2-
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Nov 28, 2007 10:03AM prayrv wrote:

Congratulations!

I'm still waiting for my 1st appeal to go through.  Because of my score (12) my onc & I decided no chemo.  That's a BIG $ savings for the insurance company.  Hope that they see it that way.

Take care.

Trish

Dx 4/27/2007, IDC, <1cm, Stage IA, Grade 2, 0/5 nodes, ER+/PR+, HER2-
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Nov 28, 2007 10:26AM - edited Nov 28, 2007 10:27AM by roseg

That's great.

You would think they'd view that as a saving device and put it on the approval list. 

Even if it indicates you should have chemo, that's when your chance of dodging the beast is best. Drugs for mets are way more expensive. 

Rose
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Nov 28, 2007 10:59AM DoreenF wrote:

woooohoooo!!!!   Congratulations ... that's fantastic!!! 

I had the test about 2 1/2 years ago and even though I had no out of network coverage - and Genomic Health - the only one doing the Oncotype DX test -  was not in my network -   my insurance covered the test ... it was strange though -  as my insurance sent a check to me  - in my name -  with no reference of what the check was for ...  

I'm soooo glad that progress is being made and that we have tests like Oncotype DX available to us ... they should be available to each and everyone of us who meet the profile for the test ...   the information is helpful -  regardless of the actual score  (low/med/high risk of recurrance) -  in making decisions ...   

Keep the good work up!!! 

Doreen  

"Cancer May Leave Your Body, but It Never Leaves Your Life" - Lance Armstrong Foundation Manifesto. Dx 4/18/2005, IDC, <1cm, Stage I, Grade 2, 0/2 nodes, ER+/PR+, HER2-
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Dec 5, 2007 04:27PM - edited Dec 5, 2007 04:49PM by mminmich

Congrats!!! This gives me hope because I too, am in the midst of my first of 3 appeals to get the Oncotype Dx covered. I am appalled by the way I have been treated by my insurance company. After the claim was denied, Genomic Health promptly mailed the appeal and my medical records to them, AND faxed it two other times, and ALL THREE times, the insurance company claim to not have received anything!!!!  We are continuing to resend the information to them until they acknowledge receipt (and calling...and calling...).  Everything is being documented of course and we will go to the state insurance board if needed. And if THAT wasn't bad enough, my insurance company (as per their customer service rep) actually told me that the Oncotype DX test was a "cosmetic" procedure, just as a mastectomy would be considered a "cosmetic" procedure. Strangely enough, a lumpectomy (which is what I had) is not considered a "cosmetic" procedure. This is the word the insurance company rep used, "cosmetic". I was speechless. The folks at Genomic Health have been beyond nice and supportive though and without their kindness, I think I would have really lost it over all this. I think this whole experience with my insurance company has been more stressful than having breast cancer.

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Dec 6, 2007 09:24AM - edited Sep 6, 2010 06:00PM by yellowrose

This Post was deleted by yellowrose.
You gain strength, courage and confidence by every experience in which you really stop to look fear in the face. You are able to say to yourself, 'I have lived though this horror. I can take the next thing that comes along.' Eleanor Roosevelt
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Dec 14, 2007 12:00PM msannie57 wrote:

Oh, go ahead and go to the state insurance department--why wait?  In New York they are fairly responsive to these kinds of issues.  In fact I've used the strategy of just telling the insurance rep that I'm calling the state insurance people and the state attorney general's office.  I got a manager very quickly.  You've certainly given the insurance companies plenty of warning.  Perhaps after the news this week from the San Antonio Breast Cancer conference about the Oncotype DX the insurance companies will change their tune.

Ann
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Dec 14, 2007 02:17PM - edited Dec 14, 2007 02:21PM by malucho1

I received the actual letter from "the department of managed health care" in CA that gives details of my victory. BTW, I have Blue Shield HMO.

Since there are others on this board who are fighting to get this test covered by their insurance, I thought some of the wording in this letter might prove helpful.

The following section of the letter was written by a doctor who was the independent "judge" of my case:

Begin quote:
"I have determined that the diagnostic procedure at issue (Oncotype DX) was medically necessary for evaluation of the patient's medical condition. Therefore, the Health Plan's denial should be overturned.

Evidence for my determination:

1. Health Plan Evidence of Coverage
2. Health Plan Medical Policy: Pathology

Additional Evidence Cited by CHDR Reviewer:

I have reviewed the submitted evidence and performed a search of the relevant medical literature. The following evidence supports my decision:

1. Paik, S. et. al. A multigene assay to predict recurrence of tamoxifen-treated, node-negative breast cancer. New England Journal of Medicine, 2004; 351:2817-2826.

2 Paik, S. et. al. Gene expression and benefit of chemotherapy in women with node-negative, estrogen receptor positive breast cancer. Journal of Clinical Oncology, 2006, 24 (23):3726-3734

3. Fisher, B, et al. Five versus more than five years of tamoxifen for lymph node-negative breast cancer" Journal of the National Cancer Institute, 2001: 93 (9): 684-690.

4. National Comprehensive Cancer Network (NCCN)-Treatment recommendations for breast cancer (www.nccn.org)

5. Harris, L. et al. American Society of Clinical Oncology 2007 update of recommendations for the use of tumor markers in breast cancer. Journal of Clinical Oncology, 2007; 25 (33): 5287-5312.

Summary of relevant patient medical history and current condition:

The patient is a 47 year old female who was diagnosed with 1.5 cm estrogen receptor positive, lymph node negative, HER 2 negative breast cancer. An oncotype DX assay was performed to access her recurrence risk and the need for adjuvant chemotherapy. The Health Plan denied coverage based upon a determination that the diagnostic procedure was not medically necessary.

Analysis and Findings:

The Oncoytpe DX assay evaluates the expression of 16 genes that were selected based upon their prognostic and predictive benefit in patients with node negative, ER-positive breast cancer. Data from the initial study as well as later analysis suggest that the genes evaluated in the calculation of the recurrence score capture overall prognosis, as well as chemotherapy benefit. The greatest utility of the Oncotype DX is in determining whether an individual patient falls into the low risk category, for which hormone therapy alone may be sufficient, or the high-risk category, for which chemotherapy followed by hormone therapy is probably indicated.

There is not unanimity of opinion among medical experts on whether the Oncotype DX assay should be routinely applied. The NCCN is split in their opinion about Oncotype testing. ASCO has approved the use of Oncotype assay in early-stage breast cancer patients for decisions regarding chemotherapy. The TAILORX trial is a large cooperative group trial, currently investigating the benefit of chemotherapy in patients with an intermediate recurrence score with the Oncotype DX assay. Subjects with high and low recurrence rates are not randomized. This trial demonstrates the validity of the Oncotype DX tumor assay and the applicability of the results in patients with low recurrence and high recurrence scores, which constitutes approximately 70% of all results.

The above data indicates it is reasonable to use this assay to risk-stratify a patient such as this one with node-negative, ER-positive breast cancer. The Center for Medicare/Medicaid Services provides reimbursement for the Oncotype DX in this subset of patients. In view of the current data, the use of Oncotype DX tumor assay was clinically appropriate. Therefore, I have determined that the diagnostic procedure at issue was medically necessary for evaluation of the patient's medical condition. The Health Plan denial should be overturned. " [end of quote]

Hope this might help someone!

Dx 5/17/2006, IDC, Stage I, Grade 2, 0/3 nodes, ER+/PR+, HER2-
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Dec 14, 2007 02:41PM prayrv wrote:

Suzy,

I have BCBS of CA (although I live in TX - company headquarters is in CA).  My question is did BCBS of MA cover your ODX in full or did you have to pay anything on the claim?

Thanks for your post!

Take care

Trish

Dx 4/27/2007, IDC, <1cm, Stage IA, Grade 2, 0/5 nodes, ER+/PR+, HER2-
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Dec 14, 2007 02:58PM JoniB wrote:

Congratulations on your victory.  It is awful that we have to fight insurance companies for our very health and wellbeing.  Many companies believe that people will not continue to appeal - and many won't.  You just proved that if you persevere, you can win!  

Two time breast cancer survivor. Recurrence after 8 years. First time 3 mm ER-, PR-, HER2+. Recurrence 4mm - triple positive.

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