UPSC, Avastin insurance coverage/denial

denyingarea
denyingarea Member Posts: 11
in Uterine/Endometrial Cancer #1
My mother lost her first-round appeal w/Independence Blue Cross today. They will only give Avastin as a single-agent, and the doc wants to give it with Taxol. The initial denial was a one-page "not medically necessary." We made our case for medical necessity in the appeal. The appeal was denied and the new denial is apparently a 10-pager saying no, "investigative/experimental." (I haven't seen the whole thing yet, but should have it tomorrow to determine the next step.) In the meantime, I'm just looking for a little support in numbers.

Has anyone had insurance cover Taxol administered with Avastin (not as part of a clinical trial)? Has anyone overcome a denial of such? Any tips?

Comments

  • Northwoodsgirl
    Northwoodsgirl Member Posts: 571
    #2
    Insurance Appeal
    What evidence did the gynecologist/oncologist use in tne appeal letter to the insurance company?
    Usually the insurance compamy will have had their medical director and product manager for cancer have done a evidence based literature search to support their opinion that the treatment protocol is considered experimental.
    There are key opinion leaders for treatment of uterine cancer that the drug manufacturers seek for input.
    Likely not an off label use as both medications are indicated for certain types of cancers. Look online at the drug manufacturers package insert and instruction for use.

    I wonder why your Mom's physician is choosing this combination of drugs.
    Has your Mom failed what is considered first line of treatment- Taxol and Carboplatin every 21 days (6 cycles) with radiation in between 3 cycles.
    Does the pharmaceutical manufacturer of Avastin have any clinical literature related to using this treatment protocol? You could call the manufacturer and ask for the product manager to inquire.
    Certainly this physician isn't the first doctor to try this combination.
    It would be interesting to see if any other Blue Cross healthplan in any other state has covered this combination.
    Frustrating!!!

    Lots of questions....sorry....trying to help.
  • Northwoodsgirl
    Northwoodsgirl Member Posts: 571
    #3
    Avastin website for appeal assistance
    http://www.genentechaccesssolutions.com/portal/site/AS/
    Above is the web address to contact Genetech the manufacturer of the drug Avastin.
    They are very helpful/
  • Northwoodsgirl
    Northwoodsgirl Member Posts: 571
    #4
    Avastin website for appeal assistance
    http://www.genentechaccesssolutions.com/portal/site/AS/
    Above is the web address to contact Genetech the manufacturer of the drug Avastin.
    They are very helpful/
  • Northwoodsgirl
    Northwoodsgirl Member Posts: 571
    #5
    Appeal Tips
    Appeal Tips for Physicians:
    Contact the insurer to find out its appeal deadline, the number of appeals allowed and the mailing address or fax number for the appeal. Submit your patient's appeals package before the deadline. Some insurers have short appeal periods. An immediate response could be crucial. Some plans allow only one appeal. Also, ask if the patient or the health care provider submits the appeal.

    Many denial letters include a telephone number for the review department for physicians to call. If the reviewer sees the merits of your argument and then approves the drug for the patient during the call, the appeals process is completed.

    Clearly state what you are requesting from the insurer in the first paragraph-reconsideration, approval of prior authorization or external review.
    Provide rationale for the treatment.
    Describe the patient's disease state, prior treatments and their response to those treatments. Discuss any other underlying health issues having an impact on treatment selection. Describe your plan of therapy and the benefits of the drug for your patient. You might also mention alternative treatments and why they are not being pursued, as well as any failed treatments. Also consider citing experts in the field who support the treatment.
    Clearly state the diagnosis and the date of diagnosis.
    Include copies of any documentation supporting your case for coverage and reference those documents in the text of your letter when appropriate.
    Summarize the major points in your letter and restate what you are requesting of the insurer.
  • denyingarea
    denyingarea Member Posts: 11
    #6
    Northwoodsgirl said:

    Insurance Appeal
    What evidence did the gynecologist/oncologist use in tne appeal letter to the insurance company?
    Usually the insurance compamy will have had their medical director and product manager for cancer have done a evidence based literature search to support their opinion that the treatment protocol is considered experimental.
    There are key opinion leaders for treatment of uterine cancer that the drug manufacturers seek for input.
    Likely not an off label use as both medications are indicated for certain types of cancers. Look online at the drug manufacturers package insert and instruction for use.

    I wonder why your Mom's physician is choosing this combination of drugs.
    Has your Mom failed what is considered first line of treatment- Taxol and Carboplatin every 21 days (6 cycles) with radiation in between 3 cycles.
    Does the pharmaceutical manufacturer of Avastin have any clinical literature related to using this treatment protocol? You could call the manufacturer and ask for the product manager to inquire.
    Certainly this physician isn't the first doctor to try this combination.
    It would be interesting to see if any other Blue Cross healthplan in any other state has covered this combination.
    Frustrating!!!

    Lots of questions....sorry....trying to help.

    Answers for Northwoodsgirl
    Thanks. After the dashes are responses to your questions.

    What evidence did the gynecologist/oncologist use in the appeal letter to the insurance company? -- I'm not sure about the doc's evidence during the peer-to-peer appeal, which failed. In the patient appeal we used the Ohio State studies, preliminary results from OCEANS and ICON7, and multiple lit reviews that establish that UPSC operates like EOC.


    Likely not an off label use as both medications are indicated for certain types of cancers -- This is definitely an off-label use, as well as not FDA approved. But as we included in our appeal, there's ample research to indicate UPSC doesn't function like other uterine cancers, yet it doesn't have its own specific clinical trials nor it is often allowed in EOC trials. Plus, it's comparatively rare.

    I wonder why your Mom's physician is choosing this combination of drugs -- Severe ascites burden, platinum resistant, chemo assay ruling out Doxil (as if the shortage didn't do that already), other complications that prevent the use of harder regimens. Radiation is not the standard of care for UPSC, particularly Stage IVb as she is.


    Certainly this physician isn't the first doctor to try this combination -- No, but most of the research has been done in other cancers. The closest to UPSC is http://www.sciencedirect.com/science/article/pii/S0090825811000217 There are no UPSC results available.

    It would be interesting to see if any other Blue Cross healthplan in any other state has covered this combination -- I've seen it covered for women with ovarian cancer, but am looking for UPSC coverage.

    -- I'm familiar with Genetech's site and we've more than met those requirements for the basic appeal for medical necessity. I'm now looking for UPSC patients who have had this combination covered outside a clinical trial setting or overcame similar denials for reasons that the treatment is "experimental/investigative."
  • daisy366
    daisy366 Member Posts: 1,458 Member
    #7
    Northwoodsgirl said:

    Appeal Tips
    Appeal Tips for Physicians:
    Contact the insurer to find out its appeal deadline, the number of appeals allowed and the mailing address or fax number for the appeal. Submit your patient's appeals package before the deadline. Some insurers have short appeal periods. An immediate response could be crucial. Some plans allow only one appeal. Also, ask if the patient or the health care provider submits the appeal.

    Many denial letters include a telephone number for the review department for physicians to call. If the reviewer sees the merits of your argument and then approves the drug for the patient during the call, the appeals process is completed.

    Clearly state what you are requesting from the insurer in the first paragraph-reconsideration, approval of prior authorization or external review.
    Provide rationale for the treatment.
    Describe the patient's disease state, prior treatments and their response to those treatments. Discuss any other underlying health issues having an impact on treatment selection. Describe your plan of therapy and the benefits of the drug for your patient. You might also mention alternative treatments and why they are not being pursued, as well as any failed treatments. Also consider citing experts in the field who support the treatment.
    Clearly state the diagnosis and the date of diagnosis.
    Include copies of any documentation supporting your case for coverage and reference those documents in the text of your letter when appropriate.
    Summarize the major points in your letter and restate what you are requesting of the insurer.

    my appeal - upsc too
    It is very disheartening to be denied needed treatment because you don't fit the mold. I fought with Aetna to get a PET scan. I got the same denial that it was "experimental" for uterine but not for ovarian. Bottom line for me was that I got the CT first and then they finally approved the PET - which cost everyone unnecessary time and money!!

    After the good fight, can you have the two chemos follow each other instead of together? If not effective then they may approve later for dual chemos like the finally did for me.

    I think this is a serious issue for us with UPSC - that we are denied effective treatment while others with ovarian get tx.

    What will it take for this to change? a class action law suit???? I really do not have a litigious spirit but wonder if this is something to consider. Any thoughts?

    Mary Ann
  • lindaprocopio
    lindaprocopio Member Posts: 1,980
    #8
    daisy366 said:

    my appeal - upsc too
    It is very disheartening to be denied needed treatment because you don't fit the mold. I fought with Aetna to get a PET scan. I got the same denial that it was "experimental" for uterine but not for ovarian. Bottom line for me was that I got the CT first and then they finally approved the PET - which cost everyone unnecessary time and money!!

    After the good fight, can you have the two chemos follow each other instead of together? If not effective then they may approve later for dual chemos like the finally did for me.

    I think this is a serious issue for us with UPSC - that we are denied effective treatment while others with ovarian get tx.

    What will it take for this to change? a class action law suit???? I really do not have a litigious spirit but wonder if this is something to consider. Any thoughts?

    Mary Ann

    I had Avastin with Cytoxin, that insurance approved.
    I knew a couple women with papillary serous OVERIAN cancer that were being treated with Avastin/Cytoxin at Slaon Kettering, so I suggested that combo to my oncologist. My insurance approved it within a week. It was a VERY easy tolerable chemo for me, almost like not getting chemo at all. Unfortunately, although I had an initial drop in CA125 after the 1st round, my CA125 climbed during the last 3 rounds & a PET scan confirmed disease progression while I was on this. My oncologist said that Avastin works better with another drug as a catalyst, thus the low dose of cytoxin with it (taken orally every day.)

    NOTE ADDED LATER:
    I forgot to mention that if your insurance approved Avastin for you, and your oncologist would want to use Cytoxin as a catalyst drug, Cytoxin is inexpensive enough that you could probably pay for it yourself. Cytoxin is an old old 'mustard gas' era drug, and in the small daily dose pill you'd take with Avastin, is really cheap at the pharmacy.

    Personally, if taxol still worked for me, I'd jump to do taxol before avastin. I think of taxol as 'the good stuff' that twice brought me into remission. Bald, but in brief remission twice, so if they'd let me, I'd go on taxol again tomorrow.
  • maryv1119
    maryv1119 Member Posts: 37
    #9
    Tips for appeal
    I'm sorry your mom must go through this. I'm a medical biller and used to be an appeals rep for a couple pharma companies (not chemo drugs).

    Your mom needs to find out if her insurance plan is self insured by the employer - this means that the employer pays Aetna/Blue Cross/ or whomever to administrate the benefits, but the employer is the final authority (because they are paying the bills in the end).

    If the plan is self insured (the insurance company or HR can tell you if it is) then you can make a plea directly to them.

    Good luck!

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