insurance again

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cave88
Regular Member


Date Joined Jul 2008
Total Posts : 76
   Posted 10/23/2009 9:01 PM (GMT -6)   
  Has anyone ever had this happen?  I just finished my fourth week of radiation.  Came home today and read a statement from the insurance company.  Says they were stopping payment until the Dr provided, physical and history information, and what the size of the tumor is.  It was too late to call insurance co or dr office.  Just curious as to why they would pay for the first few treatments and then stop.  We have had some trouble in the past with these people.  I,m afraid I will show up Monday for treatment and be denied treatment because of an insurance issue.
 
Jon
age:  46
1st psa Apr 08 3.06
2nd psa 6/16/8 4.02,  DRE showed nothing abnormal
biopsy 7/10/08 positive 5 of 12
Da Vinci 8/04/8 Parkview Memorial in FT Wayne IN 
gleason 3 + 3 = 6
prostate 27 g, 4 x 4 x 3.1 cm
Stage:  pT2cNXMX
margins:  apical margin involved
no extraprostatic extension of tumor
seminal vesicle involvement: absent
3 month psa  0.11, 11/08
6 month psa 0.12,  2/09/0
9 month psa 0.13, 5/01/09
1 year psa 0.20, 8/17/2009
 
 
 


geezer99
Veteran Member


Date Joined Apr 2009
Total Posts : 990
   Posted 10/23/2009 9:31 PM (GMT -6)   
First of all, take a deep breath. This is clearly just a SNAFU and while you may have to spend a bunch of time on the phone listening to muzak it will get straightened out.

Don't worry about your doctor -- this is not the first time that this has happened and they are going to know that things will get fixed.

If your insurance is through your employer you may be able to get help from your benefits office -- they are much less likely to be put on hold.

As you work through this KEEP RECORDS. When you called, who you talked to, what they said. Write down every single thing -- even the time on hold. This will be important if you end up having to go to your state insurance commissioner (although hopefully you will not get nearly that far.) It may be that somebody just checked the wrong box or read the wrong line so don't get dejected by my advice, solving it may not be that hard.
Age at diagnosis 66, PSA 5.5
Biopsy 12/08 12 cores, 8 positive
Gleason 3+4=7
CAT scan, Bone scan 1/09 both negative.

Robotic surgery 03/03/09 Catheter Out 03/08/09
Pathology: Lymph nodes & Seminal vesicles negative
Margins positive, Capsular penetration extensive Gleason 4+3=7
6 weeks: 1 pad/day, 1 pad/night -- mostly dry at night.
10 weeks: no pad at night -- slight leakage day/1 pad.
3 mo. PSA 0.0 - now light pads
6 mo. PSA 0.00 -- 1 light pad/day


Mbshine
Regular Member


Date Joined Aug 2008
Total Posts : 67
   Posted 10/24/2009 11:32 AM (GMT -6)   
a lawyer i have known for years and knows this area basically says we can go nuts with frustration challenging insurance companies.
 
in recent years he sugests EACH AND EVERY TIME YOU EVEN THINK THEY HAVE MADE A MISTAKE
 
 
send a note to your State insurance commissioner along with copies of the documents.
 
At that point theSTATE is your agent and surrogate and lots of pressure is off you...if and when you have to sue them you have an ally...if you never sue them they will get the message that you treat evry denial, everey mistake, every lie as seriously as they treat their decisions.
 
 
change it from patient vs insurer or provider, to the state fighting for you
 
 
mbshine

engineer55
Regular Member


Date Joined May 2009
Total Posts : 121
   Posted 10/24/2009 12:25 PM (GMT -6)   
I checked with my insurer before to see if I needed any type of pre approval and they basically said anything they need must come from the physician.  You  gave them you insurance company, I would throw it back at the doctor and not wast time with the insurance company direct.  They should know what to do.  And I would emphasize stopping in the middle is not an option.
Dx'ed 5/08 one core 2%  out of 12  3+3 gleason
DREs all negative
PSA was in the 3-4 range then jumped to 7
I have the enlarged prostate, on the order of 100cc.  After taking Avodart for 3 months  my
PSA was cut in half.
I did Active S for a year but concluded that I didn't want a life
of biopsies and Uro meetings.
DaVinci on 6/24/09  UCI Med Center  Dr Ahlering, long surgery based on size and location
Final was 5% one side all clear, but had a huge 90 grm prostate
Now we work on pee control, ok at night but sitting is a big problem.


Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4849
   Posted 10/25/2009 7:06 AM (GMT -6)   
Ditto. Your doc office got the same letter...THey'll automatically deal with it.

Age 54   - 5'11"   205lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
06/25/08 - Da Vinci robotic laparoscopy
05/14/09  - 4th Quarter PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.


Mavica
Regular Member


Date Joined Jun 2008
Total Posts : 407
   Posted 10/26/2009 9:45 PM (GMT -6)   
My experience has been that its customary for insurance companies to request confirmation of certain claims/health problems and to have their own consultants review the diagnosis, treatment, etc. I think they should so some checking, within reason. As has already been said, your specialist and primary care physicians deal with such requests regularly - and let thim respond to this one. Don't let this "blip" interfere with your focus on getting better.

Age:  60 (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; 9/09: 0.0

 

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