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Insurance denied coverage
gb5151
Posted: Thursday, January 03, 2019 4:28 PM
Joined: 2/5/2016
Posts: 12


I just got a letter from bc/bs of il denying my CK procedure. I had Gleason 3+4=7. 6 cores, 5 were 3+4 and 0ne 3+3 after 2 years of active survelience with Gleason 3+3=6 in 6 cores. My last psa was 4.0 before CK. bc/bs said the procedure was not necessary. So now I am looking at a $100,000 hospital bill. Has anyone faced this and able to get insurance to pay? The hospital said they called for pre-certification and was told none was needed, which sounded strange. Any advice would be appreciated.
gb5151
JAV
Posted: Thursday, January 03, 2019 4:57 PM
Joined: 10/29/2010
Posts: 801


How could it not be necessary ? Something isn't right here. You need to appeal, or talk to the right person at the hospital and/or BCBS. But if that doesn't work out, then it looks like the hospital is on the hook for this since they were responsible for pre-approval. Don't pay, fight this. You weren't the first CK patient, I bet. Good luck, 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
gb5151
Posted: Friday, January 04, 2019 12:44 PM
Joined: 2/5/2016
Posts: 12


thanks Jim, the hospital is trying to appeal, hopefully it will go thru.

gb5151
viperfred
Posted: Friday, January 04, 2019 3:18 PM
Joined: 10/10/2008
Posts: 852


Hi gb5151, Sorry you were denied insurance coverage. A great appeal was produced by the daughter, a paralegal, of a prostate cancer patient who was denied CyberKnife treatment coverage. She organized my appeal that overturn BS of CA denial. I had to appeal through the CA Dept of Managed Health Care which was a major pain. She also used other appeals from patients that were able to overturn their denial. Accuray provided the latest studies peer reviewed studies. Go to iprostatecancer.com and then select the iPUBMD button on the right side of the page. (These are my websites) Three appeals will be on the right side of that page. The 2nd and 3rd appeals are edited appeal templates to help patients overturn denials. I have not edited these templates in years so you will need to update the published evidence. Good Luck and let me know if you need additional help. Fred A few study examples follow: https://euoncology.europeanurology.com/article/S2588-9311(130098-1/fulltext https://www.accuray.com/wp-content/uploads/ck-prostate-sbrt-sell-sheet-mkt-ck-0717-03122.pdf https://accurayexchange.com/system/files/2018-04/Fuller_AERO.ESTRO_.2018_zinc.APPROVED.pdf https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6069023/pdf/10.1177_1533033818789633.pdf http://www.oldcitypublishing.com/wp-content/uploads/2018/06/JRSBRTv5n3p217-227Holmes.pdf https://www.accuray.com/wp-content/uploads/ck-prostate-sbrt-sell-sheet-mkt-ck-0717-03122.pdf https://ro-journal.biomedcentral.com/articles/10.1186/s13014-018-1182-z https://www.researchgate.net/publication/272625313_Stereotactic_Body_Radiotherapy_for_Prostate_Cancer
gb5151
Posted: Friday, January 04, 2019 3:42 PM
Joined: 2/5/2016
Posts: 12


Fred, thanks so much, you’re a life saver. George
gb5151
viperfred
Posted: Friday, January 04, 2019 7:55 PM
Joined: 10/10/2008
Posts: 852


Hi George, Wish you the best! Again if you need help let me know. Be ready to fight, some of insurance companies are grossly neglient! Fred
 

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