G6 3 + 3 -No treatment approved by Insurance Carrier!

See my sig for more details, but was just informed by my AS coordinator at MSKCC that my insurance carrier will NOT approve ANY treatment for a G6 PCa patient!

I am currently on AS awaiting Prolaris test results.  This carrier who is the largest in the state has denied a request from my RO for a Pelvic MRI (appealed twice already) and now says they will not authorized ANY TX (Radiation of any kind or surgery based on my numbers.  I see posters all contemplating different options all the time on here, but it appears I have NONE!  Oh well, the good news is I am content with my AS journey, but just wondered if this is the new norm with Insurance companies???  

Good point Halbert...also saw that some doctors would not cover surgery via Medicare etc.  My Insurance company is one battle after the next!  MSKCC is miffed by the whole matter and can not believe what they are seeing!

This sounds revolutionary! While I personally don't believe that very low risk men should have treatment, it has always been the choice of the patient. Now a large insurer has preempted that choice?

I know that Scandinavian countries will place VLR men in AS programs, but, those government-run health systems are VERY different than the USA.

Some men who probably would be safely in AS have said that they can't sleep knowing that there is cancer inside them, and I have to respect their opinions. Taking treatment options away from diagnosed men is a huge shift. I expect this will generate a lot of controversy. Stay tuned.

Let’s be clear. The insurance company can not deny treatment. It is denying reimbursement for the treatment under the specific circumstances. If you want the treatment then pay for it. If you want it reimbursed them seek out a different insurance company that will reimburse and use them. If you want to pursue an appeal then do so.

I am not for or against this but it is becoming more clear that some PCa shouldn’t be treated. If doctors and patients can’t make the decision then third party payouts have to. This is not isolated. There are many situations that third party payouts deny reimbursement when they judge the specific treatment as unnecessary.

As for the G9 with mets, Halbert please be more specific as to the treatment. ADT, Zytiga, surgery, Provenge, Keyttuda?? You would agree that there are established determinations that guide reimbursements for specific treatments under specific conditions.

If third payor resistance to treating non threatening indolent cancer enables more men to successfully pursue AS and avoid the side effects of treatment, then that should be a good outcome. Remember there are many experts that have long argued that G6 should not be labeled as cancer.

I agree the specifics of each case have to be determined. Even the MRI will not give you the guarantee one way or the other. But what we do know is that a true G6 is indolent by definition for nearly all men. What we also know is that those that are not presently indolent will be identified in the future by rising PSA well in advance of being threatening. That is the real value of AS. For most it can provide a long time, even lifetime of avoiding unnecessary treatment. That should be looked at as a very positive result. And for those smaller percent that do develop higher grade PCa, ASidentifies them when they are still low risk and treatable.

And if you never become a G7? Then avoiding the costs was a good thing. And, if it is that important and urgent to you, then get the MRI. We make financial decisions every day based on importance.

Remember, doctors will order tests all day long even in circumstance where they are really not necessary. So just because the doctor wants the test doesn't mean that it is really going to make a difference. I have seen studies that indicate nearly 30% of the tests that are ordered are in no way useful. This is one of the very significant areas we as a country must confront and control if we are ever going to have a chance to get our medical spending in line. As a G6, PSA 5 and one core positive I certainly hope no one has ordered a bone scan for you.

tutor_paul said...
This insurance company decision falsely assumes your biopsy has perfectly characterized your cancer.

No. That’s absolutely not the case at all. It's not that you can never get treatment coverage; rather, you can get treatment coverage when treatment is needed. We know what we know, and can make fact-based decisions on what we know. If what we know now (in such cases as described here) is that the case has been diagnosed in the low-risk category, we should act appropriately.

Appropriate actions for a newly diagnosed low-risk PC case includes NOT seeking immediate aggressive treatments, but DOES include having a 2nd confirmatory biopsy in about a year. What we know is that if it is initially diagnosed low-risk then the nature of PC doesn’t suddenly change into something else, so “rushing” is not needed or appropriate.

We know that when the 2nd confirmatory biopsy is conducted, about a quarter of men will have advanced out of the low-risk category (almost exclusively to 3+4), but we also know that another quarter of men will have NO cancer found. The rest of men (about half) will be unchanged and still in the low-risk category. Roughly three-quarters of men can then go onto an Active Surveillance program.

Men who advanced out of the low-risk category at the confirmatory biopsy (which is the category many doctors specializing in PC care or PC pathology have suggested removing the “cancer” label from) will possibly move to treatment (perhaps not if the Gleason grade 4 volume remains very low).




The point that insurance companies (or Medicare) are moving to disallow coverage for low-risk PC is neither unacceptable nor unexpected. In fact, it is both acceptable and expected. 30-years ago the treatment model (from which reimbursement models were built) for anyone diagnosed with PC was a one-size-fits-all approach. We know better today. To dbell's original question, yes, I think that this is the new normal.

Today we understand that treating low-risk PC (again, shouldn’t even be branded as “cancer”) is unnecessary. The choice to pursue treatment is always the patient’s alone, but the question is about who pays. I object to paying (through higher insurance premiums or higher taxes) for for someone seeking expensive unnecessary or elective treatments for low-risk PC the same as I do object paying for any other unnecessary or elective treatment. I say that it’s about time! Let’s spend our scarce medical resources on life-extending treatments for advanced PC, and divert expenditures away from treatments that do nothing for longevity and in fact cause a trickle-down of follow-up treatments for the unnecessary side effects which result. To those who can’t sleep because of their low-risk cases, I’d rather contribute to a couple hundred dollars-an-hour shrink to address your issues rather than a $15,000 unnecessary treatment.

Let's stop the charade and change low-risk PC to "pre-cancer," and put an end to the unnecessary hysteria which is an inevitable outcome of most cases today.

Post Edited (NKinney) : 1/9/2018 10:23:02 AM (GMT-7)

Thanks for your responses guys! Wow, we seem to have a mixed bag of opinions on this subject! All I can say is that I was ready and geared up to battle the cancer, but was not anticipating battling the insurance carriers as well!

I went into approved surgery as a low volume Gleason 6. Wound up being Gleason 7 with both lobes involved.

NKinney said...

tutor_paul said...
Sorry NKinney. If you think a random 12 core biopsy is a perfect indicator of cancer status, you are misinformed. Not that I necessarily disagree with your other 500 words on the topic!

Nope. I didn't say that.

(Neither did the insurance companies...referring now to your earlier post.)

I said that we know what we know.

If someone is diagnosed with low-risk PC, then that's what we know. We know that they were diagnosed with low-risk PC.

We shouldn't make decisions by imagining something other than what we know.

We also know enough to recognize that it is NOT a perfect indicator, and that they should have a 2nd confirmatory biopsy within about a year...but for now, they have a low-risk diagnosis. Roughly 25% will have an "upgrade" which probably indicates treatment is appropriate. (Or should it be referred to as a "downgrade?" "Upgrade" is more common.) 25% will have no cancer found on re-biopsy...that's the real "upgrade," in my mind's eye.

We know what we know.

So I didn't say that "This insurance company decision falsely assumes your biopsy has perfectly characterized your cancer", or that "a random 12 core biopsy is a perfect indicator of cancer status," but the insurance companies also didn't say this. More clear now?

What I know is... to proceed with AS I would like a bit more info./ tests beyond the 12 core biopsy ie - (Prolaris, MRI etc.) to back up the findings of the low risk cancer. And as AZ Guy has said....we have seen countless times on this site where people have surgery and find they have G7 etc, in more cores etc. So the 12 core biopsy does not give me a great certainty that all is well! No test is 100%, but more knowledge you have about your situation, the better! I need more to have a certain comfort level...that's just me!

nkinney...thanks for some clarification. Again, it is more of a mental thing for me to proceed with AS knowing that an MRI and/or Prolaris test showed (currently) low level non-aggressive cancer and that it is confined to the Prostate. I also know that AS is not a cure but just a monitoring/surveillance system which may require treatment down the road. I understand that treatment based on my numbers may not be necessary at this time, but again I would like some additional reassurances beyond the 12 core biopsy.

I wouldn't use the word reassurance because the tests you are asking about may not provide it and the situation will likely be dynamic over time. What your initial dx says is you are very low risk currently with little probability of the situation getting serious anytime soon, so current invasive treatment is not prudent.

But, you do have G6, and you need to pursue a formal method of monitoring the condition so that you are alerted early in the event it moves to a higher risk level that may indicate treatment. If it never moves to that risk level you can avoid the expense and side effects of treatment. That would be very good. Even if you have to someday treat, you will have bought very valuable time being side effect free. That too should be considered as a very good outcome.

As a comparison, I have been on active surveillance for seven years now and will continue indefinately. For me AS includes PSA test and meeting with my urologist every quarter and will continue for the foreseeable future. In the event my PSA starts going up, then additional assessments will be made to see what treatment methods will be indicated. I have been perfectly fine with the surveillance and am very relaxed about the situation. When I was first dx and treated for high risk PCa there was a lot of trepidation about the future. Since I responded well to the initial treatment I have developed a comfort level even though I am still at a significant risk of recurrence. But for now monitoring PSA is the best and least invasive and least expensive method of surveillance. Hopefully you can find the comfort that can come from AS and hope that the cures and treatments of the future and less invasive and life changing than the ones today.

Happy New Year Ken, sorry about your Jets and hoping you and Sarina are walking a warm Florida beach and not the Alaskan glacier I saw in a recent picture.

As bad as insurance companies and other third party payors can be, think of a world without them to help us all spread financial risk whether it be be our health care, car, home, liability, old age income etc. A modern society can not be developed and maintained without the risk management and financial sharing that both private and public insurance provides. I too have experienced both wonderful and awful treatment by insurance companies, but thankfully far more positive than negative. So insurance is a financial fact of life we must all deal with and hopefully navigate the negative aspects effectively. I certainly want them to be financially solvent so legitimate claims get paid and I expect them to adjudicate the claims in accordance with the agreement I have with them.

But, I like your rant and hope the PSA stays under control for a very long time.

Jack, happy new year to you guys as well. And yeah, that glacier experience was a few years ago. We are in Florida now, thankfully, and I'm trying my best not to think about my still low but rising PSA. My next 3 month PSA is supposed to be mid February. But I'm planning on waiting until early April. I'm not letting anything get in the way of enjoying at least one winter down here. If anything is lurking, I don't want to know about it.

Yeah, I get the necessity of insurance and spreading the risk. I just think they should stick to insuring people and not playing Dr.

@Nkinney... yup, it was a rant. But I meant it. To be clear, I'm not against AS in any way shape or form. I think it's a great solution for some guys. We know a true G6 is generally indolent. But we don't know for sure that dbell is a true G6. And the insurance company shouldn't be dictating that he should take that risk. Only he should be able to decide that. And maybe his significant other
I've read about guys here who were G6, but after surgery got upgraded to g8 or g9. The insurance company doesn't give. Rats a@@ about that, because as long as they deny the surgery , he'll never find out.

And what about the guys whose mental makeup is such that they just stressed out with AS. Anybody ever hear of extreme stress affecting the course of a disease?

So there's another rant.

I don't remember commenting on the mitt Romney thread