DaVinci Procedure Experimental?

New Topic Post Reply Printable Version
[ << Previous Thread | Next Thread >> ]

pa69
Regular Member


Date Joined Mar 2009
Total Posts : 260
   Posted 5/13/2009 6:29 PM (GMT -6)   
I need a little help from some of you who are knowledgeable out there. My insurance company refuses to pay for the use of the DaVinci procedure because they say it is considered experimental. After spending time in this forum I felt that it was a rather common procedure. I'm preparing to dispute their claim and if I could find out about how many DaVinci procedures have been performed it would great ammunition for me.

Any ideas?

Thanks,
Bob
Age 69, First ever PSA 7.8 taken June 2008, Biopsy July 2008, 10 of 12 cores positive, Gleason 3+3=6
da Vinci surgery December 10, 2008, catheter removed December 29 2008
St. Lukes Hospital, Bethlehem, Pa.
Dr. Frank Tamarkin

Prostate weight 73.0 grams, Gleason 3+3=6, stage pT3a
Tumor locations: right anterior apex, right posterior apex to mid
left anterior mid to base, left posterior apex to mid
extensive perineural invasion in right anterior apex, right and left posterior apex to mid
seminal vesicles negative

First post PSA < .1 Jan 16 2009
Second post PSA < .1 Apr 17 2009


lifeguyd
Veteran Member


Date Joined Jul 2006
Total Posts : 674
   Posted 5/13/2009 6:36 PM (GMT -6)   

 

I don't know the numbers, but the DaVinci system is among the most used for prostate cancer surgery.  Check out their web site (attached) and give them a call for help in educating your insurance company.

 

http://www.davinciprostatectomy.com/index.aspx
PSA up to 4.7 July 2006 , nodule noted during DRE
Biopsy 10/16/06 ,stageT2A
Very Aggressive Gleason 4+4=8  right side
DaVinci Surgery  January 2007
Post op confirms gleason 4+4=8 with no extension or invasion
no long term continence problems
Post surgery PSA continues to be "undetectable"
One side nerves spared
Bi-Mix for ED 
born in 1941


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 5/13/2009 6:42 PM (GMT -6)   
I think you spoke to the wrong person at your carrier's office. DaVinci is not experimental and has been around for 13 years. General acceptence by the FDA occurred in 2001 thus the end of the trial period. Who is your carrier? Perhaps we can find you someone with that program that has had robotic surgery with DaVinci.

You may have to fight with your insurance company. If this wasn't a mistake, they are not being very smart. DaVinci offers the shortest time in the hospital and I am certain it is no more expensive that open RP.

Tony
 Age 46 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Geason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


marang keru
Regular Member


Date Joined Dec 2007
Total Posts : 21
   Posted 5/13/2009 6:50 PM (GMT -6)   
Bob,
 
I have come to belieive that insurance companies have it in their corporate charters the golden rule of "avoid paying any and all claims.
 
With that said, and off my chest, I would suggest going to the manufacture's web site http://www.intuitivesurgical.com/index.aspx  and arm youself with as many facts as possible.  Go to the "patient services" tab, it has lots of information.  You might even consider contacting Intutitive Surgical's customer services department (888-409-4774 ext.1 ) and explain your situation - maybe they would advocate for you with your insurance company.
 
I had the Davinci procedure 15 months ago with GREAT results!
 
Good luck.

Age - 57
PSA - July 7, 2007 - 4.87
Confirming biopsy - August 30, 2007
Gleason scores of 6 (3+3) and 7 (3+4)
DaVinci surgery December 3, 2007 - Robert Wood Johnston Hospital, New Jersey
 
Cathether removed December 10, 2007
No incontinence after Day 2, December 12, 2007
Fully functioning sexual activity Day 2 after cath removal, December 12, 2007
 
Post-op pathology report confirmed Gleason of 7 (3+4), 30% involved by tumor, no positive margins.
 
afer 18 mos, continue to have no side effects (ED or incontinence)
 
Follow-up PSA blood work March, June and Sept, Dec 2008, Mar 2009 all "undetectable thus far!
 
Age now- 58
 
 


pa69
Regular Member


Date Joined Mar 2009
Total Posts : 260
   Posted 5/13/2009 6:52 PM (GMT -6)   
Hi lifeguyd and Tony,

Thanks for the info. At this point I have not spoken with any insurance company representatives. The rejection explanation was on the invoice I received from them. I'm planning to call them tomorrow and am lining up my argument. My insurance is Blue Cross/Blue shield.

Thanks again,
Bob
Age 69, First ever PSA 7.8 taken June 2008, Biopsy July 2008, 10 of 12 cores positive, Gleason 3+3=6
da Vinci surgery December 10, 2008, catheter removed December 29 2008
St. Lukes Hospital, Bethlehem, Pa.
Dr. Frank Tamarkin

Prostate weight 73.0 grams, Gleason 3+3=6, stage pT3a
Tumor locations: right anterior apex, right posterior apex to mid
left anterior mid to base, left posterior apex to mid
extensive perineural invasion in right anterior apex, right and left posterior apex to mid
seminal vesicles negative

First post PSA < .1 Jan 16 2009
Second post PSA < .1 Apr 17 2009


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 5/13/2009 7:05 PM (GMT -6)   
In the link below is a blog entry of a gentleman who had DaVinci at the City of Hope near Los Angeles and was covered by Blue Corss/Blue Shield. City of Hope only does da Vinci surgeries. They list Blue Cross and Blue Shield as acceptable insurance carriers. I hope this helps.

I do recall a person stuck with the bill because prior approvals were not sought before treatment was performed. That was a person that had UHC. Not sure how that ended up.

Tony
 Age 46 (44 when Dx)
Pre-op PSA was 19.8 : Surgery at The City of Hope on February 16, 2007
Geason 4+3=7, Stage pT3b, N0, Mx
Positive Margins (PM), Extra Prostatic Extension (EPE) : Bilateral Seminal vesicle invasion (SVI)
HT began in May, '07 with Lupron and Casodex 50mg (2 Year ADT)
IMRT radiation for 38 Treatments ending August 3, '07
Current PSA (May 11, 2009): <0.1
 
My Journal is at Tony's Blog  
 
STAY POSITIVE!


spisam
Regular Member


Date Joined Jan 2009
Total Posts : 47
   Posted 5/13/2009 7:21 PM (GMT -6)   
I had robotic surgery on January 6, 2009 in Orlando, Florida. My surgeon had my surgery pre-approved by Blue Cross/Blue Shield who I have had since 1977. The entire cost was $32,000 and my out of pocket was $1400. 

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25372
   Posted 5/13/2009 7:38 PM (GMT -6)   
Bob, I live in South Carolina, and even though I had open surgery, I know for a fact that my Blue Cross would have paid for the robotic had I chosen it.
Age 56, 56 at DX, PSA 7/7 5.8, 7/8 12.3,9/8 14.5
3rd Biopsy Sept 08: Positive 7 of 7 cores, 40-90%, Gleason 7, 4+3
Open RP surgery 11/14/8, Right nerves spared, 4 days hospital, staples out 11/24/8, 5th cath out on 1/19/9
Post-surgery Pathlogy Report:Gleason 3+4=7, pT2c, 42 grm, tumor 20%, Contained in capsular, clear margins, clear lymph nodes 
First PSA Post Surgery   2/9 .05, 5/9 .10 doubled in 3 months, new test in six weeks, then possibly off for salvage radiation
 
 


Ed C. (Old67)
Veteran Member


Date Joined Jan 2009
Total Posts : 2458
   Posted 5/13/2009 7:44 PM (GMT -6)   
Bob,
At 69 years of age are you on Medicare? If you are then you can be assured that it is covered. I'm 67 and had the Da Vinci surgery and Medicare paid and my Medicare Supplement paid the additional portion (20%) that Medicare doesn't pay.
Age: 67
PSA 9/05 1.15; 8/06 1.45; 12/07 2.41; 8/08 3.9; 11/08 3.5 free PSA 11%
Dx 12/30/08
2 cores out of 12 were positive Gleason (4+4) and (4+5)
Negative CT scan and bone scan done on 1/16
Robotic surgery performed 2/9/09
Surgeon: Dr. Randy Fagin, Austin TX.
Pathology report:
Prostate weighed 57 grams size:5.2 x 5.0 x 4.9 cm
Bilateral 10-20% involved
Gleason 4+4
both nerve bundles removed,
pT3a Nx Mx
Negative margins
seminal vesicles clean
Lymph nodes: not dissected
1st PSA test 4/7/09 result <0.1


mspt98
Regular Member


Date Joined Dec 2008
Total Posts : 372
   Posted 5/13/2009 8:37 PM (GMT -6)   
Me too here, I had daVinci robotic prostatectomy last September and I have BC/BS of Pennsylvania, no problem with coverage. In fact I think I read somewhere that almost 1/2 of all prostatectomies nationally are robotic now................. 
my age=52 when all this happened,
DRE=negative
PSA went from 1.9 to 2.85 in one year, urologist ordered biopsy,
First biopsy on 03/08, "suspicious for cancer but not diagnostic"
Second biopsy on 08/14/08, 2/12 cores positive for Prostate Cancer on R side, 1 core=5% Ca, other core = 25% Ca, Gleason Score= 3+3=6 both cores,
Clinical Stage T1C
 
Bilateral nerve sparing Robotic Surgery on 09/11/08, pathological stage T2A at surgery,
No signs of spread, organ contained,
3 0's in a row now, 7 months out
Incontinence gone in early December '08,
ED remains, uro said try oral meds and then trimix for sex only now


Dirtmover
Regular Member


Date Joined Apr 2008
Total Posts : 158
   Posted 5/13/2009 9:56 PM (GMT -6)   

This is Chris, Dirt's wife. I had the insurance coverage through my employment. It was a total of $55K. We paid $1500.00 - copay. My coverage was thru Blue Cross - there was absolutely no problem with them covering this surgery.There wasnt any pre approval or anything. Check out the City of Hope website. IT IS NOT EXPERIMENTAL SURGERY ANYMORE.  It hasnt been for some time. Keep on that insurance company...they will roll over and pay for it. You are in the hospital alot less time and a very fast recovery vs. open. Keep on them - ask the doctor to "CODE" it correctly. Alot of it is all in the coding!!! Don't let up, its worth every phone call and being put on hold      PUSH yeah ON AND GOOD LUCK

 


Diagnosed November 2007   (43 years old )
PSA 3.9 / Gleason 6 / TC1 6 cores 1 shows 25%
Sugery scheduled 5/29/08 - City of Hope - Dr. Mark Kawachi
 "First show of the day"
 and now for the new ive been waiting for
 FINAL PATH REPORT:gleason upgraded to 3+4 T2c bilateral disease,tumor involvment 5%
extra prostatic extention:absent
seminal vesical invasion :absent
pathological staging:pTNM pT2 ORGAN CONFINED
margins free of carcinoma
usable erections ;6-6-08 with little blue pill
continence; 1 pad a day, dry at night
continence a non issue at 10weeks


CPA
Veteran Member


Date Joined Feb 2008
Total Posts : 655
   Posted 5/14/2009 5:50 AM (GMT -6)   
Greetings, Bob. I had the open surgery, but my doc says that robotic is where everyone is headed. In fact, he said that while there are certain aspects of open he prefers, he may be going to robotic before long. My experience is insurance companies look for ways not to pay - keep pushing. Best wishes. David
Age 55
Diagnosed Dec 2007 during annual routine physical
PSA doubled from previous year from 1.5 to 3.2
12 biopsies - 2 positive with 2 marginal
Gleason 3 + 3 = 6
RRP 4 Feb 08
Both nerves spared
Good pathology - no margins - all encapsulated - Gleason 4 + 3 = 7
Catheter out Feb 13 - wore pad for couple of days - pad free Feb 16
Great wife and family who take very good care of me


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 5/14/2009 9:43 AM (GMT -6)   
Between BC/BS (Independence Blue Cross Personal Choice Plan) and Medicare part A I paid under $400 for robotic surgery. Either your doctor sent the wrong code or BC had a glitch. In any case it shouldn't take much to straighten it out. If you have BC/BS through your employer you might see if you can get their benefits office to go to bat for you -- they don't get put on hold.
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3 + 4 = 7
CAT scan 1/09 negative, Bone scan 1/09 negative

Robotic surgery 03/03/09 Catheter Removed 03/08/09
Post surgical pathology report. Lymph nodes negative, Seminal vesicles negative
Surgical margins positive, Capsular penetration extensive Gleason 4 + 3 = 7
At 6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.


Mavica
Regular Member


Date Joined Jun 2008
Total Posts : 407
   Posted 5/14/2009 2:48 PM (GMT -6)   
Once I made the decision to follow my Urologist/Surgeon's recommendation to have my prostate removed via the da Vinci method he told me to let his staff handle the arrangements with Blue Cross/Blue Shield, my insurer, and he specifically told me not to speak with the insurance company and to refer any call(s) I might receive from them to his office.  I followed his advice and the insurance company paid the bill.  Northwestern Memorial Hospital in Chicago has a staff person whose sole job it is to push the paperwork through the insurance companies in the manner they, the insurance companies, find acceptable.   If you haven't already spoken with the surgeon about this I'd give his office manager/assistant a call to see how they've handled the insurance company matter with other patients in the practice.  It's in the financial interest of the hospital/surgeon to have the procedure approved by the insurance companies so they should do the fighting for their patients.  Not all insurance policies are identically written, so carefully read the "fine print" in yours.


Age:  59 (58 at diagnosis - June, 2008)

April '08 PSA 4.8 ("free PSA" 7.9), up from 3.5 year prior

June '08 had biopsy, 2 days later told results positive but in less than 1% of sample

Gleason's 3+3=6

Developed sepsis 2 days post-biopsy, seriously ill in hospital for 3 days

Dr. recommended robotic removal using da Vinci

Surgery 9/10/08

Northwestern Memorial Hospital, Chicago, IL

Dr. Robert Nadler, Urologist/Surgeon

Post-op Gleason's:  3+3, Tertiary 4

Margins:  Free

Bladder & Urethral:  Free

Seminal vesicles:  Not involved

Lymphatic/Vascular Invasion:  Not involved

Tumor:  T2c; Location:  Bilateral; Volume:  20%

Catheter:  Removed 12-days after surgery

Incontinent:  Yes (1/2 light pads per day)

Combination of Cialis and MUSE (alprostadil) three times weekly started 9-27-08

Returned to work 9-29-08 (18-19 days post-op)

PSA test result, post-op, 10/08: 0.0; 12/08: 0.0; 4/09: 0.0

 


pa69
Regular Member


Date Joined Mar 2009
Total Posts : 260
   Posted 5/14/2009 8:55 PM (GMT -6)   
Thanks so much to all of you folks for your support! I got a lot of good information that will help me deal with the insurance company. I learned today that they have an appeals process that requires me to submit in writing the facts that I have accumulated disputing their rejection. I'm going to follow the appeals process to see where it goes. I'll keep you all posted when anything interesting happens.

On another note, I was talking with a coworker about my experience with PC. He told me he has been having problems for some time and has decided to take action to find out where he stands. I urged him to join this forum so he can learn from all of us that have been on this journey. i told him he has to make his own decisions based on the information he can find. I can't think of a better place to to get this information than from this forum. I sincerely hope to find him here in the near future.

Thanks again to all of you,
Bob
Age 69, First ever PSA 7.8 taken June 2008, Biopsy July 2008, 10 of 12 cores positive, Gleason 3+3=6
da Vinci surgery December 10, 2008, catheter removed December 29 2008
St. Lukes Hospital, Bethlehem, Pa.
Dr. Frank Tamarkin

Prostate weight 73.0 grams, Gleason 3+3=6, stage pT3a
Tumor locations: right anterior apex, right posterior apex to mid
left anterior mid to base, left posterior apex to mid
extensive perineural invasion in right anterior apex, right and left posterior apex to mid
seminal vesicles negative

First post PSA < .1 Jan 16 2009
Second post PSA < .1 Apr 17 2009

New Topic Post Reply Printable Version
Forum Information
Currently it is Saturday, May 26, 2018 11:27 PM (GMT -6)
There are a total of 2,966,296 posts in 325,324 threads.
View Active Threads


Who's Online
This forum has 162729 registered members. Please welcome our newest member, ian33.
260 Guest(s), 5 Registered Member(s) are currently online.  Details
pam lewellen, Rockon, island time, DTT, marigold33