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

I seem to be agreeing with just about everyone on this thread. I even posted a summation of the issue on another forum.

But, I really don't like the fact that the insurance carrier is denying dbell's request to have an MRI, which is part of his structured AS protocol. THAT makes NO sense to me. If they want to deny surgery, radiation, etc. for very-low-risk men, well, OK, some men will not be happy with that. But, to deny a diagnosed man who is entering a respected AS program from having the required monitoring tests, that is a big problem, and it can't be good for anybody in the long term.

ASAdvocate said...
I seem to be agreeing with just about everyone on this thread. I even posted a summation of the issue on another forum.

But, I really don't like the fact that the insurance carrier is denying dbell's request to have an MRI, which is part of his structured AS protocol. THAT makes NO sense to me. If they want to deny surgery, radiation, etc. for very-low-risk men, well, OK, some men will not be happy with that. But, to deny a diagnosed man who is entering a respected AS program from having the required monitoring tests, that is a big problem, and it can't be good for anybody in the long term.

This is my point in terms of the MRI denial! If they are pushing me towards AS, they must follow the AS protocol prescribed by my MSKCC specialist! My carrier put forth ridiculous parameters for an MRI....

You must be the following:

G7 4 + 3
G6 with a PSA over 20 or have multiple cores over 50% involved with a PSA over 10.
Find a nodule in the DRE

So, imagine if you had G7 3 + 4??? They may deny treatment for that as well?!?!? Wow, never thought of that!

JNF,

I don't know if you know this...so I wanted to say it: I have learned more from you at HW/PC than anyone else on any topic. This post was excellent, and others of yours from the past about insurance and Medicare, and getting signed up for Medicare and what to look for.

I just wanted to say: "thanks"

-Norm

dbell,

So I am sorta surprised by your mpMRI denial. I am not surprised that they gave you an advanced heads-up on the denial for expensive, aggressive, and to this point unnecessary treatment, but I am sorta surprised about the mpMRI (and it was an mpMRI that was requested, right?)

Why only sorta surprised?

The approval & denials—and frankly, the physician/patient requests—in the PC-world have been adhoc and chaotic. There has not been a documented protocol to follow for low-risk cases...do this, if the results are that then 6-months later do this, etc., etc. On top of that, so many new tests (as I previously mentioned) which (and we've all seen this here) sometimes get "demanded" by ["worried," "hysterical," "confused" you pick the right adjective] patients which would frankly provide the wrong or unneeded information at the wrong time for them for their current case's set of circumstances. This is not necessarily your situation, but this happens; some people just want every test that has anything to do with their case, whether applicable/valuable or not. And doctors, we know, are prone to over-prescribe tests (well documented basis; just look for example at how frequently our urologists are prescribing bone scans and CT scans for initially diagnosed low-risk cases, even though their own professional organization's guidelines, the AUA, tells them this is a waste of resources; always remember that in the US medical environment today doctors get paid by "pills and procedures").

One of the key things to remember is that the mpMRI is denied now; not necessarily forever. The message may be that your request seems out-of-sequence, not appropriate for your case today. Your initial biopsy was less than 2-months ago.

Maybe, just maybe, they are getting a handle on the adhoc and chaotic nature of requests, and are beginning to adhere to a more standardized protocol.

If I were in your shoes, here's what I would be wondering: What procedures & tests do they approve for cases like yours where you are a candidate for AS?

I think it's very plausible that "what we have here is a failure to communicate." [name that source!]

JNF, maybe you can give some insight here, too?

Post Edited (NKinney) : 1/10/2018 10:30:20 AM (GMT-7)

Boy, this sure is interesting! So it appears the evil insurance companies, while saving themselves some money, are going to save many thousands of men much unneeded suffering, even if they demand the treatment and not unlikely suffering that often goes with it. Amazing! Plus, this attitude is very likely to spread, and if it does it is going to cost urologists many millions of dollars, and the same for the hospitals. Not only will RP and RT #s plummet, but so will surgeries for slings, AUS and penile implants! This is- or may soon become- a game changer in a major way!

I suppose if there are men who can not sleep at night knowing there is a cancer inside them(not to mention one that has not unlikely been there for many years slowly growing to a level that could be detected) then doctors are just going to have to do a better job of explaining the extremely low odds of them ever dying from that. Or that some authorities refuse to even call it cancer. Or, since they are not going to get paid for it anyway, they might as well stop calling it cancer. Maybe switch to calling it pre-cancer that needs to be watched?

Wow, this is really something! It may save many patients from themselves, but it is going to be rough financially for the doctors and hospitals. Man oh man, I can tell you that if I had just been blessed with a G6, or whatever set of #s qualifies for AS, there would have been no surgeon getting near my prostate with other than his finger or at worst his biopsy needle! It looks like now there are going to be large #s of men who would have been saying "Doc, get it out of there now!" who will be forced to take the road that I would have if I could have. Very interesting!

Oh, Dbell: source: the warden in Cool Hand Luke! "I'm shaking it over here boss, I'm shaking it!"

JNf/Jack great post above and I will consider this after I speak with my AS team. If they are adamant about the MRI, then I will take this approach. Again, I am not dictating what expensive, unnecessary tests or procedures to have, but are taking direction from MSKCC AS team!

BillyBob@388 said...
Boy, this sure is interesting! So it appears the evil insurance companies, while saving themselves some money, are going to save many thousands of men much unneeded suffering, even if they demand the treatment and not unlikely suffering that often goes with it. Amazing! Plus, this attitude is very likely to spread, and if it does it is going to cost urologists many millions of dollars, and the same for the hospitals. Not only will RP and RT #s plummet, but so will surgeries for slings, AUS and penile implants! This is- or may soon become- a game changer in a major way!

Oh, Dbell: source: the warden in Cool Hand Luke! "I'm shaking it over here boss, I'm shaking it!"

BillyBob...not sure if you were busting my chops with your rant, but its all good. Not sure how anyone could side with large insurance entities nickel and diming people to save a buck regardless of long term risk etc., but I guess you guys are out there! Oh, and BTW, I am bit younger than you and have heard the quote about...."failure to communicate", but it was before my time as I am not an old movie buff.

Interesting thread; Thanks for the well-reasoned responses.

Now with respect to the OP, what could an MRI show that would be new/helpful for the patient or the MSK team?

Here are the particulars:
Age 53
DX 11/17
PSA 5.1
G 3+3
1 core of 12 - 35% involvement, confirmed by MSKCC

Post Edited (Sr Sailor) : 1/10/2018 12:34:00 PM (GMT-7)

dbell

I assume you work for a fairly large company. Often they use a third party consultant to handle benefits. In Atlanta a lot of companies use Hewitt. At some point I suggest you express your frustration to your own company's Human Resources department, not the outsourced one. They need to know if their employees are not being well served by the third parties they contract with for services. These contracts are renewable every few years and employee satisfaction is usually one of the factors used to renew.

I don't know what you would get from the ACS.

Rather, I would be amassing the protocol from all the major cancer centers like Johns Hopkins, Cleveland Clinic, Mayo, Universities and medical centers known for urologic and cancer excellence like Duke, Indiana University, Vanderbilt, University of Michigan, UCLA, UCSF, etc. The AS protocol will be on their websites and easily available. Look at papers that have been written (Tall Allen is excellent source) and presentations about AS. Check the AUS website for example. Also check the Prostate Cancer Foundation( www.pcf.org) website for treatment protocols, papers, studies and such.

Then show the consistency in the use of MRI in AS protocol in all these different leading edge institutions. This is the type of ammunition that will assist you in your appeal.

Get past the third party vendor as they did not deny the claim, the insurance carrier did. Call the company directly. If you can't get anyone to talk to you then google their website and get the contact for the Medical Director, Quality officer, Government Affairs officer or some C level person that looks like they would deal with insureds rather than investors. Often the website will have a place for you to ask a question, make a complaint, etc. Do some simple web mining and you will be amazed what you will find that can help.

To help get you going: /www.mskcc.org/cancer-care/patient-education/active-surveillance-prostate (but maybe you already had this one)

dbell said...

BillyBob@388 said...
Boy, this sure is interesting! So it appears the evil insurance companies, while saving themselves some money, are going to save many thousands of men much unneeded suffering, even if they demand the treatment and not unlikely suffering that often goes with it. Amazing! Plus, this attitude is very likely to spread, and if it does it is going to cost urologists many millions of dollars, and the same for the hospitals. Not only will RP and RT #s plummet, but so will surgeries for slings, AUS and penile implants! This is- or may soon become- a game changer in a major way!

Oh, Dbell: source: the warden in Cool Hand Luke! "I'm shaking it over here boss, I'm shaking it!"

BillyBob...not sure if you were busting my chops with your rant, but its all good. Not sure how anyone could side with large insurance entities nickel and diming people to save a buck regardless of long term risk etc., but I guess you guys are out there! Oh, and BTW, I am bit younger than you and have heard the quote about...."failure to communicate", but it was before my time as I am not an old movie buff.

Hey there Dbell! Not at all busting your chops with my rant, and I sympathize with your situation, particularly with your inability to have further testing paid for. But I do have pretty strong feelings about all the men who are- often with no real need as their risk is so small- seriously hurt for life with various PC treatments. Men who often had almost no chance of either dying, or even ever having any symptoms from- their PC. And a related situation: the recommendations- apparently being acted upon- that we not even be tested because of all of the over treatment. Which means guys with the aggressive cancers- the men who may well actually suffer and die from this disease- will end up getting diagnosed much later than they should have, when there is less chance of a good result with treatment. So some are apparently willing to throw these high risk guys under the bus just because doctors are telling the low risk guys "you have cancer and we need to get it out" or, just by using the word cancer for a very low volume G6, end up with the patient demanding of the doc "get it out now".

There seems to have been little middle ground, or common sense approach such as instead of denying high risk men a chance at a possibly life saving PSA, instead stop the doctors from scaring guys who don't need treatment into demanding treatment. Though admittedly, I can see how it would be tough to force doctors to take such an approach.

So all I was trying to say is: it seems quite an irony that the insurance companies- often thought of as the bad guys by me and others, for not being there for us after we have paid them up front- that these same insurance companies might be the ones who solve the above problem by refusing to pay for what many consider to be unneeded treatment where the cure is not uncommonly worse than the disease. And though many will disagree with me on this, IMO if they don't pay for these surgeries for the very low risk patients, even when the patients themselves(and not just their surgeons) demand surgery, there is going to be a great reduction in unneeded suffering for these low risk men. And there is plenty of suffering in this world that is a result of PC surgery, though I guess how much of it is really necessary remains up for debate. That the insurance companies- rather than the doctors- would be the reason for this decrease in suffering- just seemed a bit ironic to me. Or maybe not.

But please forgive me if I seemed to be trying to bust your chops with my rant, I was definitely not! Though I do rant, and I guess that was one, and this was another! Good luck on getting what you need to increase your peace of mind!

Oh, sorry about the Cool Hand Luke, that was NKinney asking about the reference, not you!

BillyBob@388 said...
BTW Dbell, in case you don't know, though probably you already know this: based on what you know so far as stated in your signature- and that is all you actually know, you have won the PC low worry lottery. The statistical odds of you suffering and dying from PC - even if you do nothing whatsoever, are very low. Way low. In addition, the studies show(far as I know) that even if you end up being one of the few G6s who advance, the delay in treatment does nothing- on average- to your life span. However, if you get 1 year or 10 years with no treatment, that is not uncommonly a wonderful thing. OTOH, your odds of dying from heart disease or some other more common reason- just like the rest of us- are much, much higher than your PC death risk. So, if you were a worrying man, it makes more sense for you to worry much more about those other common causes of death. If you ever find out you are a G9, you can shift your worries, but again the odds of that are quite low. I have never been able to forget my friend, who had RP in his 50s( I don't know what risk he was), then after a couple of years he had penile implant surgery, then after maybe 5 years total died of a stroke. Aren't I a ray of sunshine?

BillyBob...thanks for clarifying your rants..lol!  And yes, you are certainly a ray of sunshine...hey you made me laugh! LOL!  I am not a worrier btw as I am on AS and never thought of treatment at this time after I educated myself a bit!