17 replies to this topic

[pammartin]

I just received a denial for services at Cleveland Clinic from Blue Cross/Blue Shield, stating the BCR/ABL and BMB are experimental treatments and not covered by insurance.  I have has these tests covered since diagnosis last fall, and I called insurance company and they are on the same coding West Penn was, so the rep said they may go back and reverse the claim and not pay for the testing done at West Penn also?  Has anyone ever heard of this?  Very confused about the entire subject and if anyone has ever had the pleasure to call BC/BS you will already know when I finally spoke to someone about the denial, I would have been more productive to go out in the yard and have a conversation with the maple tree.  No offense to anyone working there but I have not had great experiences working with BC/BS.

[Trey]

Neither a BMB or PCR are treatments, of course.  A BMB is a widely recognised test for leukemia and many forms of blood cancers.  So that should never be denied.  The issue with the PCR is that it was not intended for diagnostic use, only for lab use.  But since there is no better alternative, it has become the standard test for minimal residual disease levels after BMB and FISH have become negative.  But the NCCN CML Treatment Guidelines have recognised PCR as a legitimate test for CML, so a good way to show that it is not "experimental" is to have the doc show them the NCCN guidelines.

http://www.nccn.com/.../cml/index.html

[Tom1278]

Pam, I just had a bone marrow biopsy, FISH, and PCR done during my initial diagnosis.  I, too, had some laboratory charges apparently related to the BMB denied by BC/BS.  I don't know which exact tests were impacted yet, as the Explanation of Benefits doesn't specify.

[chriskuo]

Why did you call BC/BS instead of Cleveland Clinic?  I would use the provider to run interference with the insurer.

[Happycat]

Pam,

I have BCBS in MA, got a PCR in july, no problem getting it covered. Well, as slow as hospital billing is, I might not have received  a denial yet.

Maybe it's just the way it was coded? 

I have found I get a denial of coverage for stuff for my dd, so then I call the doctor and they write a letter of necessity, and it gets covered. Just more hoops for them to jump through.

Traci

[pammartin]

Hi Everyone,

Thanks for the replies, I found some form of stomach flu on Sunday and have been on the couch/bed until this morning.  I did call BC/BS an asked them why the test was covered in Pittsburgh but not in Cleveland, even the codes where the same for each hospital.  I was at Cleveland on Thursday and spoke with the billing department, they said they are going to investigate and although as Trey mentioned it is a lab test, there could be discrepancy there.  I did discover that the PCR tests were denied in Pittsburgh also, but after resubmittal they were paid, so now it is a wait and see.  I will keep everyone posted, but it seems the PCR might be in the process of re-evaluation for BC/BS  FYI.

[pammartin]

Hi Billie,

Gentle Giant!!!!!!  HAHAHAHA, you should see him when he stubs his toe or hits his finger with the hammer, don't be standing in the line of fire or whatever he kicked is going to go sailing in the air and the hammer is likely to be thrown so far I won't find it until I ruin the mower blades when I discover it. 

He is growing still, told him yesterday he was going to have to stop, his jeans look like flood pants, he won't wear anything tight because of sensory issues so although he can get away with it he wears extra large or he has the neck and the hem yanked out so badly it looks like maternity clothes.  LOL

We went shopping on Saturday, he had to have ten new shirts, one every day of the week for the first two weeks of school, but I still haven't looked at his jean shorts, regular shorts, or those flood jeans.  Socks, underwear, and shoes are also on the list.  He did get his yearly bookbag at Aeropostale, they are a bit expensive but the one last year made it through the entire 10th grade, and he is anything but easy on them, so we went for the same thing this year.  Of course the style is different or someone might think he is using the same one from last year and that would be a horrible experience.  He is just shy of 6ft, and weighs 204, but he carries it well, I would like to get about 15 lbs off him, only because the doctor mentions it, but after the work we did this summer I am convinced his body is going to stay where it is, even with hard work.  He does not eat nearly as much as you would think for his size, less now than he used too.  And the one thing this summer he did do was work.  He keeps telling everyone he can't wait to go back to school because he will not have to use a shovel, lawn rake, trimmers, weedeater, or mowers, .

[pammartin]

After a review from BC/BS, the BCR/ABL and BMB are now considered experimental and not covered under PPO insurance plan.  This has to be a brand new policy because they have paid for several while I was seeing doctor in Pittsburgh.  I have started the appeal process and have Cleveland on board, but they will do nothing until they also receive the denial for services.  The list for these tests as necessary medical conditions no longer includes leukemia.  That is what the BS/BS rep told me today, after I was reminded I was being recorded.

Not much I can do accept appeal, anyone else out there in CML land having problems with this?  I have the PPO, which should be the better insurance, I do not have all the restrictions for an HMO or the pre-authorizations.

Very confused

[Tom1278]

Pam, I just got the full Explanation of Benefits for my BMB and related tests that they did for my intial diagnosis (FISH, PCR, etc.).  Apparently, everything was covered, and nothing was denied.  I have CareFirst Blue Cross Blue Shield PPO.

The denied lab charges I mentioned above were apparently not related to the BMB.

Each BC/BS is a separate insurance company, from what I understand, which might explain why mine was covered and yours was not.

Tom

[Susan61]

Hi Pam:  I am always on the phone fighting for different things for my mother and have done it for some friends, and always get results.  You would not believe the things that my  mother almost payed for before letting me get on the phone with different insurance.  My mother has Horizon Blue Cross/Blue Shield, and they are always wrong, and I have to fight it and prove it to them.  I wish I could do it for you to help you get this paid for.  I have never had to go through the appeal process.  These insurance companies have a bunch of idiots working for them.  Medicare even payed a big bill for my mother when she was in a Rehab after her stroke, and they have no record of paying it.  All we know she is does not owe anything now on that bill.  The squeaky wheel gets the oil.  Fight it till they get sick of hearing your name.

Now I do not know about Pennsylvania.

Susan

[pamsouth]

PamMartin,

Pam a lot of this info won't be for you, but thought it might help other with insurance questions who have BC/BS PPO UAW RETIREE ins by the auto makers.

We have BC/BS PPO out of Michigan for  UAW CHRYSLER Retiree's.  Which is even a different BC/BS PPO contract then active Chrysler (or other auto makers) employees have.  My husband son works at Chrysler and his BC/BS PPO pays most everything and he pays no premiums.  We pay premiums for BC/BS PPO UAW RETIREE, and cobra for dental and optical, plus deductibles and out of pockets.  Our insurance pays no specialists however I managed to get around BC/BS to pay for my onc, with a special code not normally used, however I have had to do many disputes and many complaints,  even filed a complaint with Blue Cross Case Manager and my Onc Manager, as I have had to get the Ok many time to use a special code, but it keeps falling between the cracks. I have even written to our city reps and complained to Congress, etc, about how terrible cancer patients are treated by their BC/BS PPO UAW insurance company, at least mine, and I have all the documentation and paper trail, never throw them away insu documents,  paper trail is good, (legal) they have their recordings for their own use, so you need a paper trail, unless you record too!!!. Did it helped, well I did get them paid, if you got the fortitude and strength.  Otherwise it could have cost me thousands. For me to get Oncology paid, TKI need to be called an ""ongoing oral chemo drug"", with a V67.2 code, that is the hitch, as V67.2 was originally used for IV infusions, but now (2006) they, BC/BS PPO UAW, have broadened the interpretation of V67.2, to ongoing chemo oral drug treatment, with paid follow up visit to oncology. The trick also is to get your onc on board with it, by getting them to call your insurance. It also depends on who you are talking to on the phone. 

This is the first year since my husband retired from Chrysler, that BC/BS has paid for a primary, they now pay 4 primary visits a year, with $25.00 co-payment. For me it is usually better if I call the number on the EOB, where the EOB Came from,  then if I call the number which is on the back of my card, which is Mi.  We live in Indiana, but Blue Cross for auto maker is out of Mich.  Now when Larry's son retiree's he won't have medical insurance at all, so I guess we have been lucky to at least have insurance.  My husband primary is now Medicare and my Medicare will be effective 12/1/12, thank God, I have been counting the years, months, and days. So Medicare is primary and BC/BS secondary.

For those that are turning MEDICARE age, be careful with the new supplement's they are offering.  Now, BC/BS and Medco will be a Medicare supplement along with other's like Indiana University Med/Hospital.  However these are different contracts then we have with Blue Cross PPO UAW.  They have a different network of doctors with different contracts.

My BC/BS has always paid for my labs.  Except for a couple of time when the lab filed it wrong. 

I get FISH/PCR, ETC every 3 months, for the past several years (2005).  Also BC/BS PPO UAW has also always paid for my Gleevec except I pay a small co-pay.  I am grandfather in, but of course if i ask, blue cross and uaw always tell me it is subject to change, as insurance is based on the world economy, so there you go.  That was another reason I really, really wanted to stay with Gleevec which is suppose to go generic in 2015 my primary doctor said the cost for Gleevec would probably drop to a few hundred.  Others patent drugs that become generic will drop to a few dollars or less, but she said there would not be that many patients on Gleevec as CML is rare, so the cost will stay up some, but still affordable compared to $6,000,00 and still going up every year.

I called the Chrysler UAW who hold the insurance funds and contracts to BC/BS.  They said most retirees are not taking the Medicare supplement BC/BS ppo and MEDCO supplement,  because the network and contract is different.  Therefore I don't know if they would continue to pay the same for my Gleevec or Labs, as I am grandfather in (subject to change, they always tell me that). 

PamM, I  oviously have a different BC/BS PPO then you have, but this may be of some help to those retired auto makers, that have BC/BS PPO UAW Retiree, be careful when you switch over to Medicare about picking up their supplements and dropping your other insurance, I wouldn't advise taking their supplements, keep your BC/BS PPO UAW, as secondary,  you may be grandfathered in to pay for certain things, that you might lose in a supplement.  In fact to persuade you to take Medicare supplement they are giving you some freebees for 2013 only.

So my primary will be Medicare and as secondary I will keep BC/BS PPO UAW, not the Medicare BC/BS SUPPLEMENT, NO MEDICARE SUPPLEMENTS!!

PamSouth

I have been having FISH / PCR every three months now for the past several years, always have paid.

[Lizzybee]

I have BC/BS of NC and they have covered everything - BMB, pcr, metabolic panel, all of it.  I'm sorry you're having to jump through hoops - it's just not right when your doctor is following the accepted protocols.

[pammartin]

Now it is semi out of my hands, I was told to contact Cleveland Clinic and have them send in data stating why these tests are needed.  What gets me is; Cleveland used the same code Pittsburgh did for the same tests.  I think that frosts my rear more than anything, had it been labeled differently, or mis-billed, but no.......everything is the same.  I just hope Cleveland does not let it ride, knowing they can come after me for the $, I know they are a large facility, but they are going to get paid one way or the other.  I hope they at least try.  I will be returning in November, I am going to call in for preapproval, if they turn me down, then I am calling Cleveland and ask what we do in this case, perhaps that, if nothing else will get them rolling?  So very frustrating.

[pamsouth]

PamM

Last thing you need is stress.  Seems like between CML, TKI, Medical Procedure, and then add Medical Insurance denial to the list,  What does this say about our health care system?

It's not for the faint of heart that for sure.  Funny then the doc tells you to keep your stress down. 

You will figure it out, just keep a good paper trail.  Throw nothing away.  Dates, time, names, notes, etc. Then they wonder why we are bit....  Not saying you, but I know I get that way, sometimes.

Impressed with your new job.

PamSouth

[pammartin]

Thanks PamS.

It is only part time, but I am filling in for the entire month of September.  They would like me to train on a full scale bus for next year.  Thinking about it, I can continue school, and have a job.  I used to worry about the 3 inch stack of medical bills on the table, drove me crazy.  I can't, and it isn't worth the stress.  One time long ago at the doctor's with my mother, the physician told her she needed to reduce her stress level, her blood pressure was too high.  She looked him square in the eye and said, 'If you show me where the button is on this body that makes the stress go away, I will push it immediately.'    I was the only one in the room that laughed, and received one of 'those' looks from my mother.  hehe

[pamsouth]

PamMart

That is what my brother used to say about stress.  I would say brother Randy my doctor keep saying don't put to much on your plate, to much stress, not good for you. You have a bad heart you should slow down, nope not him, just like daddy, got to live your life.  When your time come it comes.

Like right, with CML, TKI, HEALTH INSURANCE , and a care taker till mom died and my son and hospital and a sick husband.  Son and hubby doing well now.

Well my brother Randy would say, you can't live life without some stress, a little stress good for you.  And he did just that, lived his life to the fullest, until he died  7/24/12.  He was my perfect stem cell match donor, but never used them.  He had a bad heart for many year, quad by-pass, 3 defib, stint, and congestive heart failure.  July 2012, brother was at the hospital and they got his heart back in rhythm and his blood pressure back up to normal and some of the fluid off.  I got to see him on Sunday and the following Tuesday morning he was walking the hospital floor and fell over dead, his heart was old, tired and gave out.  He used to kid the doctors about his stem cells, he would say cut my leg off or save a bone with some stem cell for my sis.  He had a lot of congestive heart failure that last year I doubt he was in any condition to give stem cells, nor do I know if they were any good.  Just three week before he died we had a family dinner and it was nice to get to joke around with him one last time.  He was noted for his sense of humor even in stressfull times he would tell his jokes, yep just like daddy.  Well I bet there up in Heaven sharing joke, keep them clean brother.

He was 62 years old, I will be 65 Jan 1st.  Rest In Peace Little Bro, miss you.

Think he was right if you didn't have any stress you would be dead.

PamSouth

[pammartin]

Hi PamS,

I LOL when I read the first part of your message.  You wrote, 'I would say brother Randy.....'  My ex had a brother named Tom also, so to keep the conversation straight, I would always say, Brother Tom, and everyone knew it was my brother I was speaking of.  What I didn't know was many of them thought he was some type of clergy person, because I used the Brother in front of his name.

If you knew my brother, you would really understand the complexity of the joke