IMRT experimental?

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BillSD
Regular Member


Date Joined Sep 2008
Total Posts : 143
   Posted 6/29/2009 2:09 PM (GMT -7)   
Just got an Explanation of Benefits from my insurance company to my radiologist where they denied his total claim in providing my 35 IMRT treatments. Reason: IMRT is considered "experimental". To be fair, I had RRP and then adjuvant radiation.  I understand my radiologist cannot bill me, because he is an approved provider with the insurance network. 
 
Has anyone else run into this or have some words of insight or wisdom.
 
Thanks, Bill
Age 61 (59 when Dx) PSA 4.4
Biopsy 5/15/08 Gleason (3+3=6)
Bone scan and pelvic CT: clear
HT - 2 mo Casodex, 3 mo Trelstar
RRP Surgery 9/15/08 La Mesa California
Post-OP Gleason 3+4=7, Stage pT2c pN0 MX
Seminal vesicals, perineural margin, 18 lymph nodes, bladder neck: all carcinoma free
Perineural invasion & Distal Margin: Carcinoma present
IMRT adjuvant radiation (35 Treatments) End 1/27/09
PSA (10/13/08): <0.1
PSA (3/13/09): <0.1
 


CPA
Veteran Member


Date Joined Feb 2008
Total Posts : 655
   Posted 6/29/2009 2:13 PM (GMT -7)   
Greetings, Bill.  I don't have any experience with this, but I would imagine your doc will follow up with your insurance company and file the appropriate appeals.  Unfortunately, it seems that there are insurance companies out there who go by the strategy of deny, deny, deny until someone makes the right appeal.  We'll hope it all works out for you and your medical provider.  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
PSA every 90 days - ZERO's everytime!
Great wife and family who take very good care of me


Dutch
Regular Member


Date Joined Feb 2007
Total Posts : 400
   Posted 6/29/2009 2:26 PM (GMT -7)   

As with proton, I believe IMRT is covered by Medicare therefore cannot be expermintal - Medicare does not cover experimental procedures.

Dutch


Diagnosed Feb 2001  (Age 65)  Currently 73
PSA 4.8      Gleason 3+3=6      Stage   T2b
Completed Proton Therapy @ Loma Linda - 2001 - No side effects.  My journey is at: http://www.healingwell.com/community/default.aspx?f=35&m=727565
7yr PSA - 0.2
Our responsibility now is to educate men about Pca, PSA and the importance of early detection. 
 
 
 


Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 6/29/2009 3:25 PM (GMT -7)   
IMRT is not experimental. You need a higher authority at your insurance carrier claims department. You might want to show them other facilities that do IMRt on their plan.

Tony
 Age 47 (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!


don826
Veteran Member


Date Joined May 2008
Total Posts : 1010
   Posted 6/29/2009 4:42 PM (GMT -7)   
Hi Bill,

IMRT is not experimental and is an extension of well established conformal radiation techniques used in the past. You may want to have your insurance company clarify the "experimental" aspect as it applies to primary or salvage in your case. From a brief web search and postings here it appears that IMRT is not considered experimental as salvage either. Your rad onco has most likely provided similar treatment to others on your plan. Sounds like you have a rookie looking at your claim.

Best of luck.
Don
Diagnosed 04/10/08 Age 58 at the time
Gleason 4 + 3
DRE palpable tumor on left side
100% of 12 cores positive for PCa range 35% to 85%
Bone scan clear and chest x ray clear
CT scan shows potential lymph node involvement in pelvic region
Started Casodex on May 2 and stopped on June 1, 2008
Lupron injection on May 15 and every four months for next two years
Started IMRT/IGRT on July 10, 2008. 45 treatments scheduled
First 25 to be full pelvic for a total dose of 45 Gray to lymph nodes.
Last 20 to prostate only. Total dose to prostate 81 Gray.
Completed IMRT/IGRT 09/11/08.
PSA 02/08 21.5 at diagnosis
PSA 07/08 .82 after 8 wks of hormones
PSA 10/08 .642 one month after completion of IMRT, 6 months hormone
PSA 03/09 .38 six months post radiation and nine months into hormones 
 
 
 


Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4018
   Posted 6/29/2009 4:45 PM (GMT -7)   

Bill:

As others have said, IMRT is clearly NOT experimental and the procedure is routinely covered by insurance.  I recommend calling your insurance company and asking for someone in supervision...I'm guessing this will be easily cleared up.

Tudpock


Age 62
Gleason 4 +3 = 7
T1C
PSA 4.2
2 of 16 cores cancerous
27cc
Brachytherapy December 9, 2008.  73 Iodine-125 seeds.  Procedure went great, catheter out before I went home, only minor discomfort.  Regular activities resumed, everything continues to function normally as of 6/1/09.  6 month PSA now at 1.4 and my docs are "delighted"!

BillSD
Regular Member


Date Joined Sep 2008
Total Posts : 143
   Posted 6/29/2009 7:19 PM (GMT -7)   
Thanks everyone for the feedback. I'll contact my radiologist. I feel very badly for him if he has to fight every case like this. It makes me appreciate our physicians all the more. They deserve better.

Bill
Age 61 (59 when Dx) PSA 4.4
Biopsy 5/15/08 Gleason (3+3=6)
Bone scan and pelvic CT: clear
HT - 2 mo Casodex, 3 mo Trelstar
RRP Surgery 9/15/08 La Mesa California
Post-OP Gleason 3+4=7, Stage pT2c pN0 MX
Seminal vesicals, perineural margin, 18 lymph nodes, bladder neck: all carcinoma free
Perineural invasion & Distal Margin: Carcinoma present
IMRT adjuvant radiation (35 Treatments) End 1/27/09
PSA (10/13/08): <0.1
PSA (3/13/09): <0.1
 

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