Chick123
New User
Joined: 16 Jul 2006
Posts: 1
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 Posted: Sun Jul 16, 2006 3:44 pm Post subject: Blue Cross MRI Denial |
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Hi to all from a new member. I am a 58 year old male diagnosed last February with prostate cancer, Gleason's 6, PSA 7.3. I have gone through all the trials and tribulations that generally accompany this kind of brush with mortality. I am happy so far with my choice of therapy, seed brachytherapy performed three days ago. So far, so good, minimal pain and discomfort, moderate urination urgency and flow restriction. Hoping for the best!
My question here has to do with the financial obligation of my medical insurance, a high deductible PPO policy. Blue Cross is refusing to pay for the endorectal coil MRI used to precisely define the tumor, indicating it was an elective diagnosis procedure and not a medical necessity. I do not believe this to be the case.
In the beginning, I saw a local (small town) urologist after the PSA flagged a concern. He performed the biopsy, and recommended surgical excision. I was at first in favor of this therapy, but my subsequent internet survey indicated that instead seed brachytherapy might be a superior choice. Internet information also recommended an MRI to properly define the tumor before selecting the best therapy. I was then referred by a local resident with prostate cancer to a urologist (surgeon) at UC San Francisco who had a reputation of even-handedly recommending radiation as opposed to surgery based on the merits of each individual case, and so I decided to consult him. Upon his examination in San Francisco, both he and his resident told me that their digital rectal examination identified a troubling bulge at the prostate right apex (where the biopsy indicated was the majority of the tumor), and the urologist expressed concern that there might be an extracapsular extension of the tumor at that point. He agreed that an MRI was appropriate to define the extent of the tumor and determine whether it was in fact well contained within the prostate. And so an endorectal coil MRI was scheduled and performed.
The MRI results indicated that there was indeed no extracapsular extension at the right apex or elsewhere, and also no vesicular invasion. It was this diagnosis of tumor containment within the prostate proper that led me to select seed brachytherapy prostate ablation alone as the most appropriate procedure. Had there been an extracapsular extension, I might have had to consider other therapies in addition to, or in lieu of, brachytherapy, such as surgical excision or external beam radiation, in order to eliminate the entire tumor. But, of course, I never had to consider going there, based on the MRI results.
I was somewhat taken aback when, after confirming my brachytherapy decision as most appropriate with the SF urologist and having my case transferred to the radiologist, I was informed by him that the MRI was not all that useful in planning the seed insertion. Mainly the radiologist utilized an ultrasound procedure a week ahead of the surgery to map out the insertion pattern, and again during the operation to actually place the seeds. However, I note that in four weeks I will need to have a CT scan to confirm adequate placement of the seeds within the prostate. If a high resolution imaging procedure such as a CT scan is necessary to appropriately view a foreign body (brachytherapy seed) placement within the prostate, then why wouldn't an equivalent high resolution imaging procedure, namely an MRI, be necessary to appropriately view another foreign body (cancerous tumor) placement within the prostate? Also, I previously spoke only of having basic MRI imaging with the urologist. Apparently he additionally ordered an MRI metabolic study, of which procedure I was entirely unaware, and which greatly added to the time and cost of the diagnostic procedure.
Can anyone give me advice that I might use in appealing the Blue Cross denial of payment? Of course, the most important aspect is that the tumor be entirely eliminated by the procedure I have selected. But the MRI bill is just short of five thousand dollars, and so I would like Blue Cross to properly assume its obligation. I believe the crux of the matter is that while the MRI was not very useful once the brachytherapy procedure had been selected, it was critical in characterizing the tumor so as to properly make that decision in the first place, and had an extracapsular extension been evident, other procedures would have been necessary, adding to Blue Cross' financial obligation. What chance do I have of winning an appeal, and how should I go about this? Thank you in advance to any and all who may help! |
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Richard Day Gore
Experienced user
Joined: 09 Nov 2006
Posts: 69
Location: NYC
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| Posted: Tue Jan 09, 2007 8:47 am Post subject: Re: Blue Cross MRI Denial |
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It's disgusting that in America your right to survive is married to your ability to pay.
Whenever you deal with anyone in the medical and insurance world, from the receptionist to the president of the HMO, get their names right up front, and make sure they know you are writing it down. You'd be surprised at how far you can get on someone's perception of accountability.
Ultimately though, we all have to tall our congressmen and women that we no longer accept the cash-for-health slavery that has spread through our society. And that we'll vote them out if they don't aggressively work to stop it.
Regards and good luck,
Richard Day Gore
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Richard Day Gore |
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Robertgro
New User
Joined: 01 Mar 2007
Posts: 2
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| Posted: Sun Mar 04, 2007 11:58 am Post subject: BC |
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| I am no big fan of bc/bs, have avoided them so far. Your best option IMO is to sue them in small claims court. The judges are often sympathetic to cases like yours (there is no jury) and you seem to have a good, common sense case. BC may send an attorney to represent them which may turn out to be in your favor if your state is one that does not allow attorneys in small claims! Even if you don't get a judgment you can still pursue other options.[color=orange][/color] |
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