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Foundation One-Innsurance Denial

CheeseQueen57's picture
CheeseQueen57
Posts: 717
Joined: Feb 2016

So I just found out that Aetna denied the cost ($5,000) of my Foundation One testing. I intend to appeal just to jerk them around and actually may take it to the state department of insurance. Has anyone filed an appeal and can share any documentation you have found to substantiate that this has pretty much become standard of care and not experimental. Thanks in advance. 

cmb's picture
cmb
Posts: 247
Joined: Jan 2018

I described my experience with genetic testing for Lynch Syndrome and my insurer's original denial of payment here:

https://csn.cancer.org/node/315172

For my successful appeal, I referenced Blue Cross' Clinical Guidelines Lab Management Program Manual (for the time period relevant to my claim) that stated:

Three main approaches to Lynch syndrome genetic testing are appropriate in different clinical situations:

Testing those with a suspected Lynch syndrome-related cancer should begin with microsatellite instability and/or immunohistochemistry testing on tumor tissue, which is discussed separately. If these tumor tests suggest Lynch syndrome, that individual should be offered genetic testing to look for a mutation that causes Lynch syndrome.

After receipt of this appeal, Blue Cross agreed to pay my claim.

All the large insurers I've worked with have similar clinical guidelines for their medical providers. Here is one example from Aetna's site:

http://www.aetna.com/cpb/medical/data/100_199/0140.html

My testing was specifically for Lynch Syndrome, not a broader test of multiple indicators. So you may need to review another guideline for your appeal. Also, if you are covered by Medicare, see Northwoodsgirl post at:

https://csn.cancer.org/node/315182

pinky104
Posts: 567
Joined: Feb 2013

I qualified for Foundation One's support towards my bill.  When my insurance denied payment, I got all upset worrying about what I had to get done in the timeline specified to appeal my decision, as I had very little time left to do the appeal.  I called Foundation One and found out that they would appeal twice for me with my insurance, and I didn't have to do a thing.  I'm guessing that either my insurance paid for it or Foundation One wrote it off (or whatever they do in these cases) as I received my denial last summer and haven't heard from them since (and I hope I won't!).

derMaus's picture
derMaus
Posts: 476
Joined: Nov 2016

I had my F1 test last May. A few months ago they sent an authorization form for my signature, enabling them to appeal on my behalf. So far, so good...no further communication. I do like the idea of jerking Aetna around, though. Be sure to keep us posted  ;)

CheeseQueen57's picture
CheeseQueen57
Posts: 717
Joined: Feb 2016

Foundaion One told me they exhausted what they could do as far as appeals. 

pinky104
Posts: 567
Joined: Feb 2013

I'm curious as to when you had your testing done.  I'm wondering if there's a chance I'll still be made to pay, as I still haven't heard what the results of their appeal(s) have been.  I don't think I'm going to be billed, as I met their rather generous income requirements, though.  I just hope they don't surprise me and change their minds.

CheeseQueen57's picture
CheeseQueen57
Posts: 717
Joined: Feb 2016

I think my Foundation One testing was done in August 2017 and I just got their bill last week. I’ve reached out to a patient advocate association to help me with the appeal. it looks like it could have some valuable resources for others. http://www.patientadvocate.org/

pinky104
Posts: 567
Joined: Feb 2013

My testing was done right around the same time yours was, maybe a month earlier.  I hope I don't get any surprises in my mailbox one of these days!  Thanks for replying.

linmk's picture
linmk
Posts: 58
Joined: Sep 2017

energy levels are low. I'm glad that you may have found an organization that can help. Crossing my fingers for you.

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