This is surprising

jtl
jtl Member Posts: 456
in Head and Neck Cancer #1
For the last couple of weeks I have been getting a lot of thick packets of denial information from Medicare. Basically, they are denying all of my IMRT treatments because their medical review person does not belive they are medically necessary. Today I called the Onc's office and the story is that Medicare does not yet support the therapy that some of us have had like TomoTherapy and the others to spare healthy tissue and minimize collateral damage. They would prefer that we get the old technology. I am not responsible in any event but it still is unfortunate. The clinic that I went to has already asked for a re-review which was denied and now they are taking it to the next level. They are a pretty big operation so I assume they have the resources to fight this. In their opinion this is the future of rad therapy and I agree. while it may be more expensive now, in the long run it may save patients a lot of money due to less side effects. Who would have known.

John

Comments

  • Hal61
    Hal61 Member Posts: 655
    #2
    One step forward and two back?
    Hi John, thanks for sharing this. Scary is the only word I can think of. If I'm reading right, Medicare doestn't deny that you needed radiation, only that the older, more scattershot radiation would be sufficient treatment, so no legal or medical need for "IMRT"? Is that correct?

    The other idea is that in the opinion of the clinic you went to for IMRT, a return to less sophisticated and more damaging types of radiation represent the "future."

    As IMRT is the recognized standard for radiation for cancer patients now, I believe Medicare will heave a hard time turning back the clock.

    Also, if I'm not prying, you said you were not responsible in any event. Do you mean by that, that since the clinic has already accepted your payment for treatment, they will go after Medicare, and not you? Or is there another reason.

    IMRT is not experimantal medicine, and I'm flabbergasted by this.

    best, Hal
  • longtermsurvivor
    longtermsurvivor Member Posts: 1,842 Member
    #3
    Typical
    Man, this is cost-effective treatment, don't care what they think. OTOH, my IMRT has been covered by Medicare. I just today saw the first summary statements. I'll bet yours will too. It is good the group is going to bat for you. That helps a bunch. Its pretty lonely when you have to do the appeal yourself. BTW, after Medicare, I find I only owe about $80/wk for IMRT. A bargain at any price, Wish the chemo had been that kind, but it left me a huge bill.

    Pat
  • jtl
    jtl Member Posts: 456
    #4
    longtermsurvivor said:

    Typical
    Man, this is cost-effective treatment, don't care what they think. OTOH, my IMRT has been covered by Medicare. I just today saw the first summary statements. I'll bet yours will too. It is good the group is going to bat for you. That helps a bunch. Its pretty lonely when you have to do the appeal yourself. BTW, after Medicare, I find I only owe about $80/wk for IMRT. A bargain at any price, Wish the chemo had been that kind, but it left me a huge bill.

    Pat

    Pat, they are going to bat
    Pat, they are going to bat for themselves since they know they cannot charge me. I remember that the Erbitux was very expensive. I think my first infusion was $10K of which $4K was Medicare approved.
  • longtermsurvivor
    longtermsurvivor Member Posts: 1,842 Member
    #5
    jtl said:

    Pat, they are going to bat
    Pat, they are going to bat for themselves since they know they cannot charge me. I remember that the Erbitux was very expensive. I think my first infusion was $10K of which $4K was Medicare approved.

    If it is a denied service
    they actually can charge you. They are under no contract that I'm aware of that forces them to take no payment as payment for denied services. I'm speaking only of services that are denied, not approved for payment, albeit at a reduced rate.

    Best to you.

    Pat
  • jtl
    jtl Member Posts: 456
    #6
    longtermsurvivor said:

    If it is a denied service
    they actually can charge you. They are under no contract that I'm aware of that forces them to take no payment as payment for denied services. I'm speaking only of services that are denied, not approved for payment, albeit at a reduced rate.

    Best to you.

    Pat

    Not so in this case. I was
    Not so in this case. I was not notified in writing before the service was furnished that Medicare would likely not pay for the service. Therefore I cannot be held liable based on Section 1879 of the Social Security Act. It even goes on to say that if I paid any money to the provider I could get reimbursement directly from Medicare.
    Regards,
    John
  • longtermsurvivor
    longtermsurvivor Member Posts: 1,842 Member
    #7
    jtl said:

    Not so in this case. I was
    Not so in this case. I was not notified in writing before the service was furnished that Medicare would likely not pay for the service. Therefore I cannot be held liable based on Section 1879 of the Social Security Act. It even goes on to say that if I paid any money to the provider I could get reimbursement directly from Medicare.
    Regards,
    John

    Ah.....
    Now I understand. Good thing they didn't look it up in their provider manual prior to starting. Good for you.

    Pat
  • jtl
    jtl Member Posts: 456
    #8
    longtermsurvivor said:

    Ah.....
    Now I understand. Good thing they didn't look it up in their provider manual prior to starting. Good for you.

    Pat

    The letter even said they
    The letter even said they should have known and told me (in so many words). It still does not explain what the real problem is. It is pretty well documented that IMRT is used to treat scchn and that Medicare covers it. So why in my case was it found "not reasonable and necessary" and "the diagnosis is inconsistent with the procedure"? The claim was for "radiation tx delivery imrt (77418)" Apparently medical records were submitted and reviewed by the Medicare contractor's medical staff and they said "your doctor must show why you need that service". "He does this by listing your diagnosis, complaint or symptom on the claim. This would not include a routine service to "rule out" and problem". I would not say getting 35 rads is diagnostic, I did after all have scc. I may need to call them again to get some answers because it doesn't make any sense and I have a curious mind.
    John
  • jtl
    jtl Member Posts: 456
    #9
    Update
    So after receiving another boat load of denial letters I called the radiation oncogogist. The reason that Medicare is refusing to pay is because based on my diagnostic code from the pathologist it was not necessary to have IMRT or at least the newer versions and 3D would have been sufficient and cheaper. They again told me this is not my problem and they intentionally did the more expensive TomoTherapy to make a case to Medicare that it is medically necessary. Apparently they fully expected the claim to be rejected. I have no idea why my diagnosis was such that an older technology was considered adequate. They have been around for 30 years and have almost 100 offices so they obviously can afford to mess with the system.
  • longtermsurvivor
    longtermsurvivor Member Posts: 1,842 Member
    #10
    jtl said:

    Update
    So after receiving another boat load of denial letters I called the radiation oncogogist. The reason that Medicare is refusing to pay is because based on my diagnostic code from the pathologist it was not necessary to have IMRT or at least the newer versions and 3D would have been sufficient and cheaper. They again told me this is not my problem and they intentionally did the more expensive TomoTherapy to make a case to Medicare that it is medically necessary. Apparently they fully expected the claim to be rejected. I have no idea why my diagnosis was such that an older technology was considered adequate. They have been around for 30 years and have almost 100 offices so they obviously can afford to mess with the system.

    Somebody in the group may be a crusader
    and that's just AOK. The medicare beurocracy is a bunch of paper pushers. They have no real idea what they are doing, in medical parlance. As I said, I'm on medicare disability without a chance of qualifying for a gap policy. My portion of the erbitux bill ran about 600/week, for a total of about 10000. The totoal IMRT bill isn't in, but I've seen the first four weeks. The total will be about 90,000. of which I'm going to owe about 7000. In all this cancer was over $200,000.00 Hope I was worth it.
  • jtl
    jtl Member Posts: 456
    #11
    longtermsurvivor said:

    Somebody in the group may be a crusader
    and that's just AOK. The medicare beurocracy is a bunch of paper pushers. They have no real idea what they are doing, in medical parlance. As I said, I'm on medicare disability without a chance of qualifying for a gap policy. My portion of the erbitux bill ran about 600/week, for a total of about 10000. The totoal IMRT bill isn't in, but I've seen the first four weeks. The total will be about 90,000. of which I'm going to owe about 7000. In all this cancer was over $200,000.00 Hope I was worth it.

    Pat
    I doubt if they are crusading about the patients. It is all about maximizing revenue and the cost of the lastest equipment is a fixed cost so they need to make it pay. It basically costs the same for the machine to sit idle instead of working, other then the variable cost of the techs and electricity. Medicare is all about minimizing expenses, I can see where they are at odds. We are somewhere in the middle. I think the total for IMRT was billed at about $70K.

    Erbitux is very expensive which according to my Med Onc is one of the reasons for it not being used as a single, front line drug even though it is approved for that when there is a 30 year old drug that is effective in many situtations and is very cheap. Plus the oncology community is very slow to embrace change. I guess if that logic prevails there will not be a lot of new drugs in use for treating HNC. From what I have read there doesn't appear to be much gain in this disease over 30 years other than improved RT. I hope Erbitux works for us and I think it will, without the longterm side effects of the platinum drugs. But as we all know it is a crap shoot.
  • Hal61
    Hal61 Member Posts: 655
    #12
    jtl said:

    Pat
    I doubt if they are crusading about the patients. It is all about maximizing revenue and the cost of the lastest equipment is a fixed cost so they need to make it pay. It basically costs the same for the machine to sit idle instead of working, other then the variable cost of the techs and electricity. Medicare is all about minimizing expenses, I can see where they are at odds. We are somewhere in the middle. I think the total for IMRT was billed at about $70K.

    Erbitux is very expensive which according to my Med Onc is one of the reasons for it not being used as a single, front line drug even though it is approved for that when there is a 30 year old drug that is effective in many situtations and is very cheap. Plus the oncology community is very slow to embrace change. I guess if that logic prevails there will not be a lot of new drugs in use for treating HNC. From what I have read there doesn't appear to be much gain in this disease over 30 years other than improved RT. I hope Erbitux works for us and I think it will, without the longterm side effects of the platinum drugs. But as we all know it is a crap shoot.

    More chaos as the model expands
    JTL, interesting what you say. There appears to be the same lack of coherence at the upper levels of research and applied medicine. In oncology, alternative approaches, some from left field, and some, like Burzynski, seeming scientific line drives, are moved quietly aside in the wake of reliably cheap treatment and research approaches. It's not just the Big Pharma boogerman, it's a built in dyamic of sameness and caution that perpetuates itself.

    With the rising vision of an aging mega population quickly going upside down on its health mortgage, the use of advanced treatment may well decrease further.

    Relatedly, I recently listened to a radio report on British medicines' opinion of the use of PET/CT scans in the U.S. Point being that the Brit docs were appalled by the excessive frequency, calling our attitude about it akin to a feeling of "Divine Right." Hey, that notion comes from their history not ours. Start stocking up on basic antibiotics, antiseptics, and gauze; and pull out granny's old poultice recipies folks.

    best, Hal
  • jtl
    jtl Member Posts: 456
    #13
    Hal61 said:

    More chaos as the model expands
    JTL, interesting what you say. There appears to be the same lack of coherence at the upper levels of research and applied medicine. In oncology, alternative approaches, some from left field, and some, like Burzynski, seeming scientific line drives, are moved quietly aside in the wake of reliably cheap treatment and research approaches. It's not just the Big Pharma boogerman, it's a built in dyamic of sameness and caution that perpetuates itself.

    With the rising vision of an aging mega population quickly going upside down on its health mortgage, the use of advanced treatment may well decrease further.

    Relatedly, I recently listened to a radio report on British medicines' opinion of the use of PET/CT scans in the U.S. Point being that the Brit docs were appalled by the excessive frequency, calling our attitude about it akin to a feeling of "Divine Right." Hey, that notion comes from their history not ours. Start stocking up on basic antibiotics, antiseptics, and gauze; and pull out granny's old poultice recipies folks.

    best, Hal

    Hal,
    One does have to wonder
    Hal,
    One does have to wonder about the quality and related costs of medical care with the baby boomers like my self starting to hit the Medicare roles. My guess is that the latest and greatest technologies will be reserved for those who are willing and able to pay out of pocket costs and perhaps those with private insurance. I am also very surprised at the varying costs of treatments and diagnostic procedures depending on where you go for the service. A recent discussion on the cost of a PET pointed that out.
    John

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