Getting approval from Insurance Companies
Need any idea's, I am 63 so no Medicare.
I applied for 28 Proton Treatments thru Blue Cross of Il., if I cannot get that than going for SBRT 5 treatments.
Question is if anyone was turned down, what did you do to try to get approved.
Interested in more discussions like this? Go to the Proton Beam Therapy Support Group.
Dave… I am a huge proponent and beneficiary of proton, treated in 2019 at Phoenix Mayo… I had just turned 67. I suspect this is not a solution, but can you do something like Lupron for two years? Depends a lot on your personal situation. The good news is SBRT has gotten a lot better in three years. BTW, My brother worked at the Fermi Lab in the 70s, just outside Chicago, which had some roots for proton technology. Best of luck…
At the month I turned 65 began proton radiation treatment at Loma Linda, one of the original hospitals to accept proton radiation therapy as an alternative to conventional radiation.
M-Care plus Tri Care for Life (retired military). I paid absolutely nothing.
I called last week to Mayo in Jacksonville, Florida and eventually connected with the insurance acceptance people. She stated Mayo does not accept Medicare insurance. Repeat..Mayo does not accept Medicare for payment.
Just be aware of these obstacles to treatment. Timing is important for the preservation of good health.
I have been having issues with getting approval for procedures and medications from Blue Cross/True Blue Gem.
In talking with providers and insurance billing workers, I have learned my doctors had to go have a peer to peer reviews with Blue Cross admins, they told the doctors that they were denying the requests as a COST Saving Measure!
The Managed Supplement companies, Are a for profit company, looking to save their company money by denying claims/request for services.
I am Allergic to Lactose, a lot of medicines use them as fillers and binders in their tablets, etc. Blue Cross Admins would not approve the medicine I needed until I bought the one with Lactose 1st, Then, they approved the one I could take! ( I took the Lactose medicine to our Free Clinic in town, so someone else could benefit from it)
I called the Medicare main phone line, talked with them and found that I could change to simple Medicare, Medicaid ( I fell under the Qualified Medical Benefits for my State), and have a Prescription card separate from any Managed Care Plans. You could also use Good Rx or Single Care cards.
If any procedure is covered by Medicare, always ask 1st!, then the QMB will cover the secondary portion. Best to ask about this for your state coverages.
I hope all this information can be helpful for you. Best wishes.
Mayo in AZ accepted my husband's Medicare….no problem. We had a supplement to Part B, however. If AZ accepts it, can't imagine why any Mayo would not. Perhaps they do not accept it if VA is involved.
Mayo definitely accepts Medicare.
Thanks for the comment. As mentioned, have Medicare and Tri Care for Life. Tri Care is known to be one of the best!
That said, living near Jacksonville Mayo, I thought a yearly examination would be an "experience" being at the Mayo Clinic..historically one of the great ones in health care management. I called and the insurance gal said.."no go".
From this comment, I will call again or perhaps write to validate. Thanks/RH
I’m not familiar with this treatment, but have you tried social security disability? I have been on disability since 2006 due to a major motorcycle accident ( I was 45) at that time I remember reading something about cancer applicants did not have to jump through a lot of hoops like I did. I did a little search for you last night and I saw there may be something you can get. I’m sorry I don’t remember exactly what it was about, but do a search on ss cancer disability as you know better yourself of what you may or may not be able to do. I’m just trying to help and there may be help for you through them. I wish you luck through all of this. BTW, I just happened to see your post, I’m not a part of your group. Wishing you the best!
Insurance denial is real! It is often done as a 'knee jerk' response to your application, as a cost-saving measure. PUSH BACK! You have the right to formally appeal your denial (per your plan's coverage documents), and if that fails, you may have the right to an outside hearing on your case.
I was originally denied Provenge treatment by my (then) PPO, and I filed a written appeal – denied again. But, at each stage, the insurance company had to get more and more specific as to WHY they were denying, and I could then counter these specific items. Finally, I was offered an 'in-person' hearing in front of their appeals board. I arrived with a written statement, copies for all. The moderator said "no one comes in this well prepared!". After countering all of their objections, I prevailed and was approved for Provenge treatment, which gave me a 6 year remission.
Follow all the appeals requirements. Never give up until all avenues are exhausted.
Thanks for that info, hopefully my insurance will.
Have a call scheduled next with with Mayo in Jacksonville. At that time, I will confirm the denial or acceptance.
Again, I now have Medicare plus TriCare for Life (managed by Humana)
From what I understand, proton radiation therapy is expensive. I was told while at Loma Linda the cyclotron is as big as a football field which spins and throws off the protons. Costs of installing such a device exceeds tens of millions of dollars. I was told it cost Loma Linda 250 million in 1993 (this amount is not verified).