Blue Cross/Blue Shield coverage for SBRT?

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JockMT
Regular Member


Date Joined Mar 2015
Total Posts : 40
   Posted 9/10/2015 3:13 PM (GMT -7)   
I have been told by the insurance person in the CyberKnife clinic I'm planning treatment in that she thinks my federal employee group plan does not cover SBRT for prostate cancer (and she showed me the statement in our benefits literature that SBRT is not "medically necessary"), though the literature of the administrator (Blue Cross/Blue Shield of Montana) specifically states that it does cover SBRT for PCa.  We are waiting for word from the administrator.  Any tips or enlightening war stories?

rob2
Veteran Member


Date Joined Apr 2008
Total Posts : 1131
   Posted 9/10/2015 3:22 PM (GMT -7)   
Hopefully others will chime in. I've seen some posts where insurance denied proton beam but this is the first I've heard. May want to find someone to unravel the insurance puzzle for you. Before I had any treatments, I made sure I was covered. Sounds like you are doing the same thing.
Age 48 at diagnosis (55 now)
PSA increased from 2.6 to 3.5 in one year
biopsy March 2008 - cancer present 6 out of 12 cores; gleason 7
Robotic Surgery May 9, 2008 - Houston, TX (Methodist Hospital)
Pathology report -gleason 8, clear margins
PSA 2008 - 2013 <.04; new lab 2013<.01; 2014 .02; 2015 .03
continent at 10 weeks (no pads!)
SRT 06/30/15 - 08/21/15 - 39 sessions

suzhtz
Regular Member


Date Joined Jul 2015
Total Posts : 219
   Posted 9/10/2015 4:39 PM (GMT -7)   
At the Cleveland Clinic, we were told that 80% of SBRT treatment plans are pre-approved by insurance without question. The remaining 20% are "usually" approved on appeal.

Farmerboy
Regular Member


Date Joined Mar 2014
Total Posts : 34
   Posted 9/10/2015 9:16 PM (GMT -7)   
I live in Kansas and was told that Blue Cross Blue Shield would not cover SBRT in Kansas. If I was old enough for Medicare I would have been fine. I called out to Colorado Cyberknife in Lafeyette Colorado and they didn't hesitate at all. They said come out and get the treatment and leave the insurance to them. That scared me to death. But they assured me they would collect and they did. I got word they collected less than a month after my last treatment. I would highly recommend them.
Age 59. One of 12 cores positive. 20% involved. Gleason 6. Biosy Feb. 2014

PSA 6.77 Dec. 2013 PSA 4.19 Feb. 2014. Did some major things for diet and supplements between PSA tests.

Father died of prostate cancer nine years after diagnosis with very similar biopsy initially as mine. He did radiation and thought he was "cured."

Finished SBRT radiation April 8, 2014. 36.25 Gy total in 5 fractions.

stixandstonz
Regular Member


Date Joined Nov 2012
Total Posts : 173
   Posted 9/11/2015 5:43 AM (GMT -7)   
BCBS, fed plan, of Florida covered Proton with no questions. Good luck, I hope that you get the answer you are hoping for. Nothing worse than having to change treatment options because of the insurance company's reluctance to pay. I am pretty sure they took your premiums for all these years without complaint.
Cheers,
Kris
Diagnosed at 51, 7/12 PSA 4.0, DRE negative.
Gleason 8, 3 of 12 cores positive. Left Apex GS 4+3=7 10% of specimen, Left Mid GS 4+4=8 10% of specimen, Left Lateral Apex GS 3+4=7 60% of specimen. 3 of 12 cores positive.
Proton at UFPTI 8/12, finished 1/13, no incont or ED
PSA 01/13 .1; 4/13 .3; 7/13 .3; 10/13 .3; 01/14 .4; 04/14 .5; 07/14 .6; 10/14 .6; 01/15 1.0; 04/15 .3; 07/15 .3

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3411
   Posted 9/11/2015 6:18 AM (GMT -7)   
It depends on your plan and the coding. In all probability they have limited or no experience with SBRT for PCa and haven't entered it into their coding system. I suggest you appeal with very solid SBRT info and request they add it to their payment code system. You might enlist TallAllen to speak with their Medical Director as your advocate. Otherwise, stick to the other proven treatments they already approve such as brachytherapy (HDR and seeds) and IMRT/IGRT.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 February 2011

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3562
   Posted 9/11/2015 7:57 AM (GMT -7)   
If the SBRT provider agrees to a payment that's lower than the competing treatment, it gets approved ! Same for Proton or anything else....
Age now 72 . Diagnosed G-9 6/2010
RALP Sept 3 2010, pos margin, one pos vesicle nodes neg. Post Op PSA 0.9 SRT, HT. 2-15-'11 PSA <0.1 10/'11, <0.1 2/12, <0.1, 4/12 <0.1, 9/12, 0.8 3/13, 0.5 6/13, 1.1, back on HT
Eligard + Casodex PSA 0.04 10/2013 PSA 0.32 on 1/14.On 6/14 PSA 0.4, "T" 5. On 10/14 PSA 0.6, "T"-11 1/2015, PSA 0.1

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7184
   Posted 9/11/2015 8:06 AM (GMT -7)   
Is it correct, then, that MediCare does pay for it?

Does that mean that BCBS MediCare Advantage Plan pays?

Mel

JNF
Veteran Member


Date Joined Dec 2010
Total Posts : 3411
   Posted 9/11/2015 8:28 AM (GMT -7)   
Mel, it isn't about Medicare as that comes from the federal government for people over age 65. It is about the treatment by the private insurance (BCBS) company. And it all depends on the state, the specific company, network and coverage option. While Medicare coverage is universal, the private companies are oriented to the specific region.

BCBS Medicare Advantage (which only applies with Medicare for those over 65) will vary across the country with costs, networks, coverage etc. Your version may be different in Michigan than my mother-in-law has in Florida.

JockMT doesn't indicate he is on Medicare. Rather, it appears he is in the Federal Employee's health insurance plan indicating to me he is still working. It appears to be an employer sponsored group insurance issue with nothing to do with Medicare.
PSA 59 on 8-26-2010 age 60. Biopsy 9-8-2010 12/12 positive, 20-80% involved, PNI in 3 cores, G 3+3,3+4,and 4+3=G7, T2b.
Eligard and Jalyn started on 10-7-2010. IMRT to prostate and lymph nodes started on 11-8-2010, HDR Brachytherapy December 6 and 13, 2010.
PSA < .1 February 2011

Nomar Lupron 4 Me
Veteran Member


Date Joined Apr 2013
Total Posts : 1922
   Posted 9/11/2015 8:32 AM (GMT -7)   
Mel - In my case Medicare and AARP/United Health Care supplement plan F paid for all of my SBRT by Dr Chris King at UCLA, but not sure if that translates to Medicare Advantage which has either a zero or a much lower premium than plan F that covers all co-pays and deductibles.
screen name was LupronJim

66 - DX 64 2/13 PSA 3.68 (6 mo doubling) Gleason 9 (4+5)

T1CN0M1B stage IV w. 7 of 12 cores worst ones 70% right PNI

oligometastatic at Dx 5 tumors 1 right sacro, 2 on
T4 & T9, none visible on 5-21-14 whole bodyscan

Lupron 3-28-13 to 4-2-15
Zytiga June '14 to May '15
PSA < 0.01, T < 3 on 5/14
DHT < 5
Prostate shrunk from 50.4 to 15.0

Provenge in Sept & SBRT in Oct

compiler
Veteran Member


Date Joined Nov 2009
Total Posts : 7184
   Posted 9/11/2015 9:41 AM (GMT -7)   
Lupron Jim:

Thanks for your response. I find this whole thing rather confusing.

I keep thinking that if MediCare covers it, then my BCBSM (Michigan BCBS) must cover it as one would think it covers all that PLUS some stuff.

But, that is not the case, I guess. I remember Allen seemed to indicate that MediCare itself varies via regions.

I just started this new insurance setup on 9/1. Haven't used it yet. First use will be my next set of blood tests -- I see the vampire in one week.

I've already did some investigations on its drug coverage, which is administared by Catamaran (Teacher's pension plan in Michigan).

With my at-work cadillac plan, I was paying $10 for a 3-month supply of generic Casodex. It will be $35. with the new plan. Still...not really bad.

If my PSA behaves this time and a few months later, I'll be on HT vacation, so I might not need to order any of that stuff!

Mel

hrpufnstuf
Regular Member


Date Joined Mar 2012
Total Posts : 312
   Posted 9/11/2015 11:39 AM (GMT -7)   
stixandstonz said...
BCBS, fed plan, of Florida covered Proton with no questions. Good luck, I hope that you get the answer you are hoping for. Nothing worse than having to change treatment options because of the insurance company's reluctance to pay. I am pretty sure they took your premiums for all these years without complaint.
Cheers,
Kris


Looking at your signature I am puzzled why it took so long for your proton treatment. Looks like 4 months. And your PSA trend seems unusual unless you had HT at the beginning and for a few months afterwards.
Age 69 DX 06/14 1 of 24 cores positive, 5% involved, GS 7 (3+4)
2nd opinion from JH GS 6 (3+3)
3rd opinion from UFPTI GS 7 (3+4)
mpMRI Duke; SV biopsy 10/2014 negative
proton at UFPTI 11/14-01/15
PSA:
11/14 11.2
01/15 6.6
07/15 2.5

stixandstonz
Regular Member


Date Joined Nov 2012
Total Posts : 173
   Posted 9/11/2015 1:15 PM (GMT -7)   
hrpufnstuff,
Not to steal the thread, I had 6 mo HT beginning 2 mo prior to Proton. Changed profile to show the PSA bump @24 mo and ran out of room.
I am guessing that my nadir is 0.3, glad you are on a downward trend.
Cheers,
Kris
Diagnosed at 51, 7/12 PSA 4.0, DRE negative.
Gleason 8, 3 of 12 cores positive. Left Apex GS 4+3=7 10% of specimen, Left Mid GS 4+4=8 10% of specimen, Left Lateral Apex GS 3+4=7 60% of specimen. 3 of 12 cores positive.
Proton at UFPTI 8/12, finished 1/13, no incont or ED
PSA 01/13 .1; 4/13 .3; 7/13 .3; 10/13 .3; 01/14 .4; 04/14 .5; 07/14 .6; 10/14 .6; 01/15 1.0; 04/15 .3; 07/15 .3
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