Saturday, October 11, 2008

Scan Day and Insurance Issue Continued

It’s almost that time again. I get a new scan this coming Wednesday on 10/15/08. It will be a CT scan of the head and neck using contrast. I’ll also get blood work and a chest x-ray. My tests will be followed by a clinic visit with my oncologist (hopefully he’ll have some preliminary good news from my various tests) and then a visit with the Supportive Care unit. It’s going to be a very very long day. I have a few new ailments which are bugging me. My vision has changed and I have a bump on my finger. Without cancer, both of these would be totally trivial. A visit to an eye doctor and my family physician would more than likely alleviate any concern. But, with cancer, every ailment, no matter how remote or trivial, takes on a greater magnitude of anxiety.

Other than my tests and clinic visit, I’m going to try and enlist my oncologist’s support to help fight my insurance company. Although the insurance company did the right thing by paying for all past chemo treatments, they did the wrong thing by denying payment for future use of my most recent chemo regimen. Here’s the problem. Chemo drugs are approved by the FDA for specific cancers. The drug companies target the common cancers because a drug which helps fight lung cancer (215,000 new cases per year) for example will have more customers than for non-common cancers. “Common” cancers are defined by the American Cancer Society as cancers which have 35,000 or more new cases per year. There are 13 of them (see reference 1 below). Head and Neck (H&N) cancer is not one of the 13. Since H&N cancer is not high on the cancer hit list, the number of drugs actually approved for its treatment is limited. However, once a drug hits the market (i.e., it has been approved by the FDA), doctors have a fairly high degree of discretion in prescribing that drug to treat other types of disease. Many of the professional medical people with whom I talk believe that H&N cancer cells behave in a similar fashion to those of lung cancer cells. So, when they exhaust their use of cancer drugs approved for H&N cancers, they may turn to lung cancer drugs. This is considered off label drug use. Drug companies are not allowed by law to market drugs for off label use, but doctors are allowed to use them for off label use when they believe they are medically necessary. That is what my doctor did for me back in December of 2007. But, my insurance company decided unilaterally to put a policy in place on 7/15/08 that made the use of this particular drug, Avastin, no longer reimbursable for off label use. What this means is that someone who has never met me and has only a superficial knowledge of my case is denying payment for future treatment when the chief of Head and Neck Oncology at one of the best cancer hospitals in the world has determined that this drug is medically necessary to treat my disease. The insurance company knows that research and drug funding for H&N cancers are minuscule when compared to the common cancers and that proving that a cancer treatment is useful for a specific cancer is a very expensive proposition. So, since my insurance company’s unilateral decision may have an impact on my future treatment and literally my life, I’m going to take my case to my oncologist and see if he will assist me in helping the insurance company see this situation from my perspective. My insurance has been good to me up until this point and I’m not out to make a national issue out of this. But, remember, this could happen to you. You’ve worked many years, you’ve paid insurance during all those many years and one day your insurance company says… you’re not covered even though your health plan documents say you are and your highly qualified medical professionals say this is your best chance at survival. This is scary stuff folks and should be taken seriously. On top of all this, I don't want to waste my oncologist's time with my insurance issues. I would much rather see him curing cancer. If anyone out there has any tips for me in this situation, please post them or send them my way.

That’s it for today. I’ll let you all know the scan results as soon as they have been finalized. Thanks for checking in and take care of yourself.


1 comment:

Meg Rodgers said...

Thank you for your post on our blog- Waeger Will Win. Your survival story came just at the right time. We'll pray for positive results for your scan tomorrow.

With respect to the insurance issue- ugh. Have you tried reaching out to the patient advocacy program at Genentech, the company that makes Avastin? Pharma companies may give people access to drugs for free if insurance doesn't cover them. I am not sure of the particulars of their program, but here is a link to the Avastin patient advocacy portion of their website.

Again, best wishes for continued health.