Insurance Co denies request for an MRI! GRRRRRRRR!

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dbell
Regular Member


Date Joined Nov 2017
Total Posts : 30
   Posted 12/7/2017 4:23 PM (GMT -7)   
My MSKCC RO suggested a Pelvic MRI!
DENIED because I did not meet the following criteria:

G 7
PSA higher than 20
Doctor found a tumor
G 6 must have at least one core more than 50% and a PSA higher than 10

So as you see below, I do not qualify....We are appealing, but very frustrated. Any advice???? rolleyes shocked mad
Age 53
DX 11/17
PSA 5.1
G 3+3
1 core of 12 - 35% involvement, confirmed by MSKCC
AS currently - awaiting MRI 1/18

island time
Veteran Member


Date Joined Dec 2014
Total Posts : 1294
   Posted 12/7/2017 5:24 PM (GMT -7)   
My Proton therapy treatment had to be appealed twice. The third time it went across their desk....it was approved. (I ended up not using it)

So keep appealing.

On a personal note dbell.....this stuff doesn't stop me. It's wrong for some insurance wonk to presume they know better than a specialist from a world-renowned cancer treatment center as to what is the best course of treatment for a cancer patient. That just don't float my boat. I don't care what the fine print says. It pisses me off just reading about it.

If it's denied again.....submit again. The squeaky wheel gets the grease.

I think if that happened to me ... I wouldn't be above calling my lawyer and having him type up a letter putting the insurance company on notice that if this cancer isn't treated as MSKCC's experts says it should be....it's on them. 100 per cent. But I'd exhaust every option before doing that. That's the doomsday scenario. Maybe your doctor knows how to word it differently. Keep submitting.....don't stop.

That's me.

good luck I think you'll get the scan

Tall Allen
Veteran Member


Date Joined Jul 2012
Total Posts : 8951
   Posted 12/7/2017 5:30 PM (GMT -7)   
Have a template mapping biopsy instead - it's better anyway.
Allen - not an MD
•PSA=7.3, prostate volume=55cc, 8/17 cores G6 5-35% involvement
SBRT 9 yr onc. resultsSBRT 7 yr QOL results
•treated 10/2010 at age 57 at UCLA,PSA now: 0.1,no lasting urinary, rectal or sexual SEs
my PC blog

island time
Veteran Member


Date Joined Dec 2014
Total Posts : 1294
   Posted 12/7/2017 5:32 PM (GMT -7)   
Someone at that insurance company has the latitude to approve that test. It's just a matter of getting through the front door.....and letting them know....it's worth their while.
PSA 2010 thru 2014...4.0 +/- .7
Dx 12/14 @ 56 yo...2 cores G6 <5%, 1 core G6 20%, 1 core HGPIN.
RALP 11/25/15...3+4. 3 to 5 mm surgical margin 15% involvement pT2+
2/16-.01...4/16-.00...7/16-.00...10/16-.01...1/17-.01...4/17-.02...7/17-.02
10/17-.02

dbell
Regular Member


Date Joined Nov 2017
Total Posts : 30
   Posted 12/7/2017 6:27 PM (GMT -7)   
Thanks guys for all the encouragement....I'll keep on pushing and will get the approval! Nice when the insurance carrier looks to save a few bucks when people's lives on the line?!?! mad rolleyes
Age 53
DX 11/17
PSA 5.1
G 3+3
1 core of 12 - 35% involvement, confirmed by MSKCC
AS currently - awaiting MRI 1/18

CuriousCharles
Regular Member


Date Joined May 2017
Total Posts : 186
   Posted 12/8/2017 1:09 AM (GMT -7)   
Just to add to what Tall Allen said,

"transperineal template-guided prostate mapping biopsy"

"A procedure .... in the diagnosis of prostate cancer and in planning prostate cancer treatment. Ultrasound is used to create a map of the prostate so the whole prostate gland can be seen in three dimensions and divided into 24 areas. Needles are then inserted through a template into each of the 24 areas and tissue is removed to be checked under a microscope. Also called TTMB."

No needles through the rectum. Under sedation, guided needles go through the skin in front of the rectum into the prostate. No ambiguity as to what is shown on an MRI image. Provides actual biopsy tissues for pathology examination and evaluation of absence or presence of cancer, gleason scores, etc.

Charles
Dx Nov 2013 Metastatic Prostate Cancer at Age 65
Numerous Bone Mets and Lymph Nodes, PSA 5,006
ADT Lupron + Zometa, PSA Nadir 1.0
Resistance after two years.
Short rechallenge Casodex.
Oct 2016 Provenge
Dec 2016 Start Xtandi, PSA 95
Sep 2017 Xtandi PSA Nadir 1.2
Nov 2017 PSA 1.7

dbell
Regular Member


Date Joined Nov 2017
Total Posts : 30
   Posted 12/8/2017 7:57 AM (GMT -7)   
CuriousCharles said...
Just to add to what Tall Allen said,

"transperineal template-guided prostate mapping biopsy"

"A procedure .... in the diagnosis of prostate cancer and in planning prostate cancer treatment. Ultrasound is used to create a map of the prostate so the whole prostate gland can be seen in three dimensions and divided into 24 areas. Needles are then inserted through a template into each of the 24 areas and tissue is removed to be checked under a microscope. Also called TTMB."

No needles through the rectum. Under sedation, guided needles go through the skin in front of the rectum into the prostate. No ambiguity as to what is shown on an MRI image. Provides actual biopsy tissues for pathology examination and evaluation of absence or presence of cancer, gleason scores, etc.

Charles


Thanks Charles and Tall Allen for your input. I will explore this avenue with my MSKCC specialist. Thanks again, Dave
Age 53
DX 11/17
PSA 5.1
G 3+3
1 core of 12 - 35% involvement, confirmed by MSKCC
AS currently - awaiting MRI 1/18
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