27 replies to this topic

[Badger]

So, I've been having PCRs since August of 2009, and they have always been covered by insurance. Starting last year, a new single CPT code was supposed to replace the six previously used by insurance companies. Every time the test was done in 2012, the new single code was rejected, but the old codes were still accepted and the test was covered. Suddenly, this year none of the codes are accepted, with the explanation that the PCR isn't generally accepted within the medical community as a standard test for this disease. I have Blue Cross/Blue Shield of Illinois, not some good for nothing policy. Now I'm in the process of appealing the claim. Has anyone else been running into this? If so, have you been able to rectify it?

[janne]

Badger,

We did have a  previous thread on this subject. It sounds strange that they would not cover it. I also have Blue Cross Blue Shield so am wondering if I will get some ridiculous notification in the mail along these lines also.

This is the thread that I found: http://community.lls...e/151367#151367

[Marnie]

I am on BCBS and have run into the same issue.  My PCR tests were always 100% covered until 2013.  I called and talked to someone last week.  Her response was that it falls under genetic testing, which is not covered.  So I'm being billed $100 each time I have a PCR test.  Please let me know if you find out anything about the coding issue.  I'll do the same on this end and we can compare notes. 

Marnie

[Cks]

My name is Cindy and this is the first time I have posted here.  Was diagnosed with CML in September of 2011. I have BCBS of Illinois insurance and as of 2013 am having the same problem.  The test is denied because "there is insufficient evidence establishing that the service is generally accepted in the medical community and/or proven to be effective according to peer review clinical literature"

I have talked to BCBS and they said the wrong code was billed.  My doctor's office sent notes but just received another letter from BCBS denying the claim.  Not sure what to do and doctor's office can't seem to help.

[janne]

I am sure there is LOTS of data out there to support the use of PCR testing for monitoring CML patients and you folks out there who have such excellent sources of information, I would expect you to know exactly what they are. I wonder if in any of these cases of denial, they are differentiating between those who have achieved CCyR and those who have not. I cannot believe the language they are using, i.e. "insufficient evidence". This is truly ridiculous. I will have my first PCR test of 2013 this week and I will be waiting to see what my BCBS says as well.  

Current Guidelines:

"Current practice guidelines from Europe Against Cancer and National Comprehensive Cancer Network (NCCN) for management of patients with CML call for use of quantitative Reverse Transcription Polymerase Chain Reaction (RT-PCR) assays during the initial workup of patients with chronic phase CML, in monitoring for minimal residual disease, and in identifying patients who may be at a high risk for relapse."

[Badger]

This is the same language used in the letter I received that denied my appeal. It has nothing to do with the level I'm at (i.e. CCR, MMR, etc), as they are not aware of where I'm at. I'm currently being tested every three months, and it's going o cost me $900 each time out of pocket.

[Marnie]

Yikes!!  I thought my bill of $100 was bad!  Not sure what I'd do if I had to pay $900 every 3 months.  When my employer switched to an HSA, I had to pay $4000 out of pocket when I picked up my Sprycel.  That was rough.  Switched to my husband's insurance as soon as I could, but that was a tough year.   I talked with my onc today, and his response to my comment about insurance not paying for PCR tests, was that he thought it was probably due to the changes in healthcare, and that we would see more in the future.  Not very encouraging.  Also not encouraging that my PCR results weren't in.  Oh well. . hopefully they'll be in soon.  I don't wait on bated breath like I did the first couple of years.  Those of you on BCBS and having the PCR issue, please continue to post, and if a solution appears, let the rest of us know.

Marnie

[janne]

I am trying to find some information on this subject as I am expecting with my BCBS that I will have to deal with it also. There were three new CPT codes developed in 2012 for BCR-ABL testing which combined several other codes. I do not know why this would only be a problem now in 2013 if incorrect coding were an issue.

I have found several sites which seem to contribute to these coverage decisions one of which is a bcbs technology evaluation site.

I could find no specifics on this site to support their denial of PCR testing claims.

I emailed the contact person at this site with a request to send me any research or evidence that supports that PCR testing is not appropriate for monitoring CML. I will let all of you know what I hear back.

[chriskuo]

What is the test that they will cover?  It is not enough for them to say what they won't cover.

[Badger]

Just replying so this topic stays on the first page for a while. If anyone covered by BCBS of Illinois manages to get their PCR covered, please let me know what hoops you had to jump through.

[mdszj]

We should try to get someone to speak up about this on our behalf, like the LLS or Amer Cancer Society, or some of the big name CML doctors, such as Druker, Cortes, etc.  Every other special interest group has their own lobbyists, why cant we ??

[Badger]

Perhaps someone on this board that sees one of the big-name doctors could ask them to do a peer-to-peer call with a contact at BCBS to see what the deal is. I don't know if this is limited to BCBS of Illinois or if it's BCBS-wide.

[janne]

Marnie does not have BCBS of Illinois I do not believe and she also had trouble with this. I do not know what state Cindy is in who also commented.

I have some information on coding that I will share but I will start a new thread becaues I do not want to clutter up and divert this thread since you had a specific question directed at BCBS of Illinois subscribers.

[mdszj]

I have BC-BS Federal and I think my wife said we paid around $300 for a PCR I recently had.  I will try to double check that figure.  How much does a PCR test cost before insurance?

[Marnie]

You are correct.  I do not have BCBS of Illinois, I have BCBS FEP, which is nation-wide. 

I am interested in your information on coding.  Will look for the new thread.

mk

[Marnie]

Curious, bdszj.  If you don't mind my asking, are you on Standard or Basic?  I read thru the two plans very carefully, and Basic was much better for our situation than Standard.  Odd, since Standard has better coverage for most things.  With Basic, you must be VERY careful to use a preferred doc, or everything comes out of pocket.  But drug coverage is far better on Basic.

Marnie

[mdszj]

Marnie - we have standard coverage.  Generally I think it is pretty good.  ALso good for prescriptions: I pay $6 for my hypothyroid meds (SYnthroid) and $80 for 90 day supply of Sprycel 100.

Are you also a fed??

[Marnie]

My husband is a fed and I am on his plan.  You may want to look thru the two plans.  The prescription drug benefits for Tier 4 drugs are much better on the Basic plan than on the Standard plan, I think.  Until 2013, my PCR tests were completely covered.  Now I'm being charged $100, though in looking at the plan, I think it should only be $75.  I will make some more calls when I have some time (the job is killing me right now. . .no time for anything).  I haven't looked at the Standard plan as closely as the Basic, but we made a choice based on my cml and how the two plans related to my medical needs.  You can go the FEPblue site and download the benefit book and compare the plans side-by-side.

We are in Colorado, but I assume that the FEP plan is consistent nation-wide. . .though perhaps different tiers of employees have different options.  

Marnie

[Marnie]

Just re-read your post.  Hmm. .  . I pay $120 for my 90-day supply of Sprycel 100.  Interesting.  What I see when I look thru the two plans is that on Standard I would pay a percentage of the cost of Sprycel.  On Basic, I pay a flat fee.  I guess I need to check to see what the cost of Sprycel is to the insurance company.  Maybe they've negotiated a better price than I assume that they have.  I wonder if BCBS would actually answer the question of how much they pay for Sprycel. 

Marnie

[mdszj]

I wonder if it depends on what state you are in.  I live in PA.