Has anyone else had the experience of being denied insurance coverage for Provenge treatment? I was told, via a denial letter from Group Health Cooperative of Seattle, on 10-30-13, that I do not meet the criteria for Provenge treatment, They have stated the criteria as follows:
1 - Diagnosis of prostate cancer that has metastasized to soft tissue or bone
2 - Testosterone level below 50 ng/dL
3 - Two sequential rising PSA levels 2-3 weeks apart, or other evidence of disease progression
4 - Use restricted to cancer therapy to Provenge alone
5 - maximum three infusions per lifetime
According to them, I do not have two sequential rising PSA's or other evidence of disease progression, and would not be using Provenge as monotherapy.
At diagnosis, I was staged as T3BN1M0, PSA 52. Lupron has lowered my T level to way below 50 (meeting criteria 2). I then developed metastatic lesion on T2 vertebra (meeting criteria 1 & 3). Lupron is allowed for provenge treatment, no other cancer therapy (meeting criteria 4).
I have filed an extensive appeal on 11-3-13, stating all backup info. They have all my medical records - I can't imagine that they did not check my files.
I have been told 2-4 weeks.
Latest update - 11/25/13
Group Health Cooperative Seattle has denied my appeal seeking coverage for Provenge treatment.
They state that, since my last radiation treatment for bone mets, I have not had 3 rising PSA's, and have not progressed.
They are not taking into account the progression from non-metastatic to metastatic, and the months of rising PSA's prior to the discovery of L3 metastatic lesion, which has since been spot radiated. According to all the published standards I can find, I do meet the requirements for Provenge treatment.
Apparently, they think that all of this is within the bounds of being non-castrate resistant.
I'm not done with them yet...outside appeal is still available.
T3BN1M0, Psa 52 at Dx 9/11
Immediate Lupron - continuous
IMRT 3/12, 10 weeks
PSA dropped to <0.02, then began rapid rise
Single vertebra met located 3/12, 3 wks radiation
PSA dropped to <0.02 after 5 weeks, and remains there!
Post Edited (Kayakbob) : 12/1/2013 5:48:01 PM (GMT-7)