Friday, September 26, 2008

Current Status and Insurance Issue

Hi. It has been awhile since my last post. Here’s what’s happening. I finished my Avastin chemo treatments on August 18 2008. That was my 11th and last treatment for this drug. My doctor had originally wanted to go with a 12th treatment on September 17 2008. Those plans changed when my health insurer decided they would not pay for it, the high cost of the treatment, and my doctor deciding that 11 was the lucky number. It’s actually a bit more complicated than this, but I felt okay with the outcome. I’m scheduled for my next scan on October 15 2008. I’m trying not on focus on that set of tests while hoping for the best and preparing for the worst.

I had a significant insurance issue that began 3 weeks ago. The issue is now resolved, mostly to my satisfaction, but it created a high degree of anxiety. Here it is in a nutshell. My insurance company paid for my first 9 Avastin chemo treatments. Before beginning these treatments, my doctors checked and said my insurance would cover them. I was always a bit bothered by how expense each treatment was. On 9/8/08 I received an Explanation of Benefits letter from my insurance company that excluded the Avastin drug that they had previously paid for 9 times. The treatment for the drug delivered on 7/16/08 (my 10th treatment) was not covered. Upon calling my insurance company, I was informed that they would not pay for my prior treatment on 8/18/08, nor any future treatments with this drug for my type of cancer. After carefully reading my 370 page health SUMMARY plan document (get it, 370 pages is the summary), I came to the conclusion that this treatment was definitely covered. It was a chemo treatment and an FDA approved drug. I called my insurance company and after a few discussions came to find out that they put a new internal policy in place on 7/15/08 (one day before my denied 7/16/08 treatment) that excluded coverage of this specific drug for off label use. They told me I could find it on their website under “Providers,” under “Policies,” and then searching for some obscure drug code. After a dozen phone calls, emails, faxes, etc. later, over a 2+ week timeframe, my insurance company decided to do the right thing and pay for my 10th and 11th treatments. I think they reached this decision based on paying for the first 9 treatments and not providing any notice as to a change in their internal policy. The power that they have to place a new policy into effect for a specific drug that is clearly inconsistent with the 370+ page summary plan document is downright scary… as if people don’t have enough to worry about these days. There were many restless nights filled with stress and high anxiety around this whole experience. The lesson learned for me in this is to confirm all expensive treatments in advance directly (and by that I mean directly and take names, dates, and notes) with my insurance company.

On a more positive note, I’m feeling relatively well, continuing to work on my speech by practicing talking in front of a mirror, trying to enjoy each day, and doing some projects around the house. If this upcoming scan is clean and then the scan after that is clean (January 2009), I will begin thinking longer term.

That’s it for today. Thanks for checking in and take care of yourself.