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Renewing the question on insurance coverage for PCR testing ?

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#1 janne



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Posted 12 July 2013 - 06:47 PM

I would like to throw out the question once again: Are there any new or ongoing issues with claims denials from Blue Cross Blue Shield with any other states out there for  PCR test claims?

My test from April is still under review.

I also had another discussion via email with the contact person at the BCBS TEC (technology evaluation site). Her second response to me is as follows:

"I am sorry that you did not find my first response helpful. There is not any BCBSA national reference policy that states that this type of testing is not supported by peer-reviewed literature. There is no TEC Assessment on this testing. We have not issued any information that states that BCR-ABL testing for CML is not medically necessary. Since each Blue Cross and Blue Shield Plan is independently owned and operated, the local Plan's policy is what would have been used to process your claim. That is why it would be best if you contact them."  (See previous post http://community.lls...message/162559# )

I have not yet heard that other insurance companies other than BCBS are denying these claims, unless I have missed something.

I find it hard to believe that 39 states with BCBS plans are making this decision of denial of payment independently of one another and I have communicated that to the BCBS TEC people. I am wondering if anyone besides Badger has had any success in appeals on this subject. I know that PamMartin had hers denied. Marnie I believe had her copay increased. There was someone else who had commented and I do not remember who or which state.

Thank you for all your contributions !


Dx'd: 8/2008. Started Gleevec 400 mg 11/08. 

Drug break 2011.

Started Tasigna 4/11 450 mg.

Reduction to 300 mg Tasigna 1/2012.

PCRU 9/2012.

12/2012 Detectable.

PCRU 4/2013 through 3/2015. (Reduced to 150 mg 7/2014)

12/2015  ? slightly detectable at probably less than 0.01% per Mayo Clinic.

4/2016 PCRU. Still at 150 mg Tasigna.


CESSATION: stopped treatment 7/20/2017. 

9/6/2017:  barely detectable at 0.01%. 

12/11/2017: PCR at 0.09% (did not do the monthly PCR testing.) 

12/18/2017: Inevitable call from Onc. Started back on Tasigna at 150 mg. (Considering Sprycel low dose.) 

#2 Trey


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Posted 12 July 2013 - 08:33 PM

The BCBS TEC response is a grammatical butchering of the Queen's English.  It is difficult to use so many double negatives in one small paragraph, but this was a work of art.  However, the double negatives say they have no issues with the PCR testing, and no policy against using them.  Given that, they should approve the claim.  But they end up saying the local BCBS office can make any determinations they please, even disregarding national BCBS guidance.  Very odd.  So it seems the local BCBS office needs to explain this to you.

Jumping ahead, the rationale will be as follows:

PCR manufacturers state that their equipment is not authorized for medical diagnostics, only lab research.  They all say this because their lawyers know the PCR results are not very accurate or consistent, and they do not want to be sued over lack of accurate diagnostics.  But the manufacturers also know their equipment is used for diagnostics.  The problem is that we need PCR testing to be used for medical diagnostics if we are to know our status during minimal residual disease (MRD) below CCyR.

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