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After having Space0ar process, insurance says it's not covered
SteveK364
Posted: Sunday, September 23, 2018 7:39 PM
Joined: 6/26/2018
Posts: 69


Well, I had the SpaceOar implanted last week, and today I opened a letter from my insurance company -- UnitedHealthcare -- who said that this treatment won't be covered because it is considered "experimental/unproven." They also said I had 180 days to appeal. With that in mind, I have a few questions for anyone who may have some knowledge in this area -- including the doctors on this forum. 1. Has anyone here experienced a similar issue? How did it turn out? 2. What are the chances of a successful appeal? 3. I believe the hospital who is doing my treatment checked all of my coverages beforehand. Wouldn't they have known -- and would have told me -- if SpaceOar wasn't covered? 3. In case I end up having to pay for it out of pocket, how much does SpaceOar typically cost? Thanks for your feedback! Steve

SteveK364


radsrus
Posted: Monday, September 24, 2018 8:07 AM
Joined: 10/10/2008
Posts: 4435


Fight with the insurance company. And yes, the hospital should have gotten advance approval and told you if it was not approved.

Clinton A. Medbery, III, M.D. Southwest Radiation Oncology buddy@swrads.org
JAV
Posted: Monday, September 24, 2018 4:52 PM
Joined: 10/29/2010
Posts: 800


Sounds like it's the hospital's problem. Don't worry about it now. After treatment you can deal with it. Who did the procedure ( and billed ) ? If the hospital, you can always refuse to pay because the hospital should have gotten pre-approval and I bet the hospital may just absorb it because of the CK treatment insurance payment. Play it cool for now. But this isn't legal advice, Jim V.

Treated with CK 4-2011.  Gleason of 3+4 , PSA 3.7 , two cores positive, 5% & 12%
 PSA on 7-13 0.3  PSA on 11-13 0.3 PSA on 5-14   0.3  
PSA on 7-14   0.2 PSA on 11-14  0.2 PSA on 3-15 0.2
PSA on 7-15, 0.2 PSA on 7-17 0.1 PSA on 1-18 0.13
SteveK364
Posted: Monday, September 24, 2018 5:29 PM
Joined: 6/26/2018
Posts: 69


Good advice, Jim. My doctor (radiation oncologist) at St. Joe's did the procedure.

SteveK364


SteveK364
Posted: Tuesday, September 25, 2018 3:36 PM
Joined: 6/26/2018
Posts: 69


Good news on the insurance front. The hospital said that there was a miscommunication between them and the insurance company and that it was their (the hospital's) fault. So, they will take care of the bill. So, it was nice to get that news today. I even got a call today from the hospital's director of radiation oncology who explained what had happened.
Chico
Posted: Thursday, September 27, 2018 9:57 AM
Joined: 10/10/2008
Posts: 446


Stevek364. Happy to hear that the billing issue has been resolved. Dealing with ProCa is enough to have on your plate. While I did not have the "space oar", I did have markers implanted. For me, that was the difficult part of the process ( after the decision go go with CK). Now just go for the sessions and relax during the process. The first session is interesting when you watch all the CK motions. After that, it's more of a routine that's a little boring and waiting. Please continue to report on your progress. Chico CK Procedure Nov 2007 Aug 2008 PSA 0.24 March 13     2009 PSA  0.17 September 30   2009  PSA  0.37 March 18             2010 PSA 0.19 September 2011  PSA  0.20 September 9  2012 PSA  0.21 September   2013 PSA  0.19 September   2014 PSA  0.23 September   2016 PSA  0.21 September   2018 PSA  0.26
JAV
Posted: Thursday, September 27, 2018 3:31 PM
Joined: 10/29/2010
Posts: 800


Good to hear, Steve. I wonder if the hospital monitors this Forum ? Jim V.

Treated with CK 4-2011.  Gleason of 3+4 , PSA 3.7 , two cores positive, 5% & 12%
 PSA on 7-13 0.3  PSA on 11-13 0.3 PSA on 5-14   0.3  
PSA on 7-14   0.2 PSA on 11-14  0.2 PSA on 3-15 0.2
PSA on 7-15, 0.2 PSA on 7-17 0.1 PSA on 1-18 0.13
SteveK364
Posted: Thursday, September 27, 2018 5:42 PM
Joined: 6/26/2018
Posts: 69


Thanks, Chico. Yes, it will be interesting for sure. The most difficult part will probably be drive and the early morning enemas. Wow, it's been 11 years for you, huh? Did you have any side effects from the treatment? Where did you have it done? Thanks again, my friend! Steve

SteveK364


SteveK364
Posted: Thursday, September 27, 2018 5:46 PM
Joined: 6/26/2018
Posts: 69


Oh, I don't know, Jim. Probably not. They said that by the time they got confirmation that my SpaceOar procedure wasn't covered, it was too late, because I was already prepping for it. So, they decided to go ahead with the procedure and sort out the insurance issue later.

SteveK364


Chico
Posted: Friday, September 28, 2018 7:22 AM
Joined: 10/10/2008
Posts: 446


Steve, I had my procedure done at Overlook Hospital in Summit NJ. When I had my procedure there had been 20-25 Procedures done for Prostate CK. They had been using the CK for a number of years, BUT NOT FOR PROSTATE. There were issues back then about Insurance Coverage similar to your ""experimental/unproven"" category. I was not sure I was going to be covered but went ahead with the procedure and tit was subsequently approved.. Some guys, back then, had to do through extensive challenges to get their original insurance denials reversed (e.g.Viperfred From Fred Kinder(2)) . I was the first patient from my medical group to have the CK for Prostate done at Overlook ( there had been other CK procedures, but not for Prostate). I was very fortunate to have had very little, if any, side effects of the procedure. I had five (5) sessions and drove to and from then on my own. Back in my days, there were a lot more "new issues" being addressed on the CKForum ( emotional , financial, etc) since there was not a lot of information out there. If you have times when you are just cruising the internet, log on to the Archived CK Forum to review what we "old folks" were discussing 10 years ago. http://www.cyberknifesupport.org/forum/default.aspx?f=10&p=1&x=25&ord=ld chico
JAV
Posted: Saturday, September 29, 2018 7:39 AM
Joined: 10/29/2010
Posts: 800


Hi Chico ! Glad to hear you are doing well. Jim V.

Treated with CK 4-2011.  Gleason of 3+4 , PSA 3.7 , two cores positive, 5% & 12%
 PSA on 7-13 0.3  PSA on 11-13 0.3 PSA on 5-14   0.3  
PSA on 7-14   0.2 PSA on 11-14  0.2 PSA on 3-15 0.2
PSA on 7-15, 0.2 PSA on 7-17 0.1 PSA on 1-18 0.13
SteveK364
Posted: Saturday, September 29, 2018 9:18 AM
Joined: 6/26/2018
Posts: 69


Chico, you were pretty brave to move forward with CK not knowing if you're insurance would cover it, and knowing you were one of the first to have prostate treatment at Overlook. Sounds like everything turned out quite well for you, which is great. I'll check out that forum that you mentioned. Thanks. Steve

SteveK364


Chico
Posted: Saturday, September 29, 2018 11:16 AM
Joined: 10/10/2008
Posts: 446


Steve, In my case, I was the first from my the Medical Group I belonged to, but was among the first 20-30 who had the procedure for 'prostate" at Overlook ..The Group at Overlook had been using Ck for other procedures ( Brain I believe). My own Urologist, had never had a patient who was treated with CK. I had done a lot of posting on the Former CK Website ( archived http://www.cyberknifesupport.org/forum/default.aspx?f=10&p=1&x=25&ord=ld ) before making my decision. I really was quite a basket case when I was told I had PCa. My GP felt something during my exam and recommended I see a Urologist. While my PSA was only 1.40 My Gleason Score of 5 ( 3.2) and 6 ( 3.3). I was told that I could do " watchful waiting" or Prostectomy / Radiation - and that Overlook Hospital was doing CK and that I should consider all of the options. My Urologist had performed 1000s of Prostectomies and would follow my decision. After Speaking the Drs at Overlook, I decided on CK ( I really did not want surgery radical/robotic whatever). I joined the CK Forum : Date Joined Jan 2007 and began asking "lots of questions". The medical professionals who supported the site at that time, provided me with a lot of information, as did members of the Forum ( esp Fred Kinder who was battling with the disease and the insurance companies at the time. Anyway, I did not want to have Cancer, I did not want to have any procedure, and was afraid of the entire situation. I was "VERY FORTUNATE TO HAVE AN EXCELLENT PCP, and an Outstanding Medical Group - Practice that I was associated with and to have come through the whole process to my present state. If you are interested in my frame of mind at the time, Here is a link to my fist post on the CK Forum where I started my many questions leading to my final decision. http://www.cyberknifesupport.org/forum/default.aspx?f=10&m=9962 Hope you are as successful as I was.
SteveK364
Posted: Sunday, September 30, 2018 6:19 PM
Joined: 6/26/2018
Posts: 69


Chico, it's cool to see that the forum goes back more than 10 years now and that many of the same doctors who were posting back then, are still participating today. That's excellent! Also, it seems that CK is being accepted more and more as a reliable and proven form of treatment for people.

SteveK364


gb5151
Posted: Friday, January 04, 2019 10:55 AM
Joined: 2/5/2016
Posts: 12


glad it worked out for you steve. I just finished my ck treatments and received a denial letter from my insurance carrier. my insurance carrier said that I had adenocarcinoma of prostate t1c, gleason 3+4=7, psa 4.0. it was denied as not medically necessary. they also said there was no documentation of negative bone scan. the hospital said they called for pre-approval and my insurance carrier said it was not necessary. it looks like I may be on the hook for the $100,000 bill if they are just going to point fingers at each other. any advice out there?
gb5151
SteveK364
Posted: Friday, January 04, 2019 2:53 PM
Joined: 6/26/2018
Posts: 69


Thanks, gb. I'm no expert, but it seems to me if the hospital moved forward with your procedure based on the understanding that you were covered, THEY should be responsible. I would fight it. You have a solid ground to stand on. Good luck, and keep us posted, OK?

SteveK364


DXM
Posted: Friday, January 04, 2019 2:59 PM
Joined: 9/10/2016
Posts: 20


"...they also said there was no documentation of negative bone scan..." What?? The chance of detectable bone metastasis with a PSA of 4 and that Gleason is so close to zero that it might as well be zero. What insurance company is it that is so incompetent? No competent doctor (unless he owns a bone scan machine) would prescribe a bone scan.

DAMorris
viperfred
Posted: Friday, January 04, 2019 9:18 PM
Joined: 10/10/2008
Posts: 850


Hi Chico, You are great, nice to see you are still helping patients through this mine field. It has been 11 1/2 years since completion of CyberKnife treatment, seldom login, Thanks for letting me know about Ron and the appeal issue. Sad to see the negative outcome (disease progression) of Watchful waiting and active surveillance which are only viable if the patient has a limited life expectancy. Years ago sent a long letter to the USPSFT when they recommended against PSA screening because it did more harm than good. I listened to doctor explain, via a webcast, their logic against PSA screening. Will never forget one reason, the doctor explained the risk of infection from the blood draw for the PSA test. This is an incompetent statement as the PSA blood draw is typically done along with (an annual physical), CBC and Lipids They failed to consider the risk factors vs biological control and quality of life based on the specific treatments. The majority of risk factors, were from surgery, death, anesthesia complications, infection, blood loss, urinary incontinence and ED. What their report did expose is the high risk and over use of surgery based on PSA screening. Until there is a screening test that confirms our prostate cancer as indolent (75-80%) or aggressive(25-20%) with a miserable ending if not treated early. Men need to make informed choices! My Opinion Fred
viperfred
Posted: Friday, January 04, 2019 10:35 PM
Joined: 10/10/2008
Posts: 850


Hi Steve, Go to gb's thread if you need appeal help. Fred
 

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