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IMRT experimental?

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Posted 6/29/2009 4:09 PM (GMT -5)
Just got an Explanation of Benefits from my insurance company to my radiologist where they denied his total claim in providing my 35 IMRT treatments. Reason: IMRT is considered "experimental". To be fair, I had RRP and then adjuvant radiation.  I understand my radiologist cannot bill me, because he is an approved provider with the insurance network. 

Has anyone else run into this or have some words of insight or wisdom.

Thanks, Bill

Posted 6/29/2009 4:13 PM (GMT -5)
Greetings, Bill.  I don't have any experience with this, but I would imagine your doc will follow up with your insurance company and file the appropriate appeals.  Unfortunately, it seems that there are insurance companies out there who go by the strategy of deny, deny, deny until someone makes the right appeal.  We'll hope it all works out for you and your medical provider.  David

Posted 6/29/2009 4:26 PM (GMT -5)

As with proton, I believe IMRT is covered by Medicare therefore cannot be expermintal - Medicare does not cover experimental procedures.

Dutch

Posted 6/29/2009 5:25 PM (GMT -5)
IMRT is not experimental. You need a higher authority at your insurance carrier claims department. You might want to show them other facilities that do IMRt on their plan.

Tony
Posted 6/29/2009 6:42 PM (GMT -5)
Hi Bill,

IMRT is not experimental and is an extension of well established conformal radiation techniques used in the past. You may want to have your insurance company clarify the "experimental" aspect as it applies to primary or salvage in your case. From a brief web search and postings here it appears that IMRT is not considered experimental as salvage either. Your rad onco has most likely provided similar treatment to others on your plan. Sounds like you have a rookie looking at your claim.

Best of luck.
Don
Posted 6/29/2009 6:45 PM (GMT -5)

Bill:

As others have said, IMRT is clearly NOT experimental and the procedure is routinely covered by insurance.  I recommend calling your insurance company and asking for someone in supervision...I'm guessing this will be easily cleared up.

Tudpock

Posted 6/29/2009 9:19 PM (GMT -5)
Thanks everyone for the feedback. I'll contact my radiologist. I feel very badly for him if he has to fight every case like this. It makes me appreciate our physicians all the more. They deserve better.

Bill
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