Insurance Denial Tumor Marker Test

Hatshepsut
Hatshepsut Member Posts: 336 Member
edited March 2014 in Colorectal Cancer #1
Hello. My husband is a stage 4 colon cancer survivor, diagnosed in May 2006 with surgeries in May 2006 and October 2007 and chemotherapy treatment. He is feeling great. I am grateful beyond my ability to express my feelings for my husband's positive response to his treatment.

On a negative note, however, as I've posted before, our path has taken us into conflict with my husband's insurer, Blue Cross (now Anthem) of California over coverage issues.

First, Blue Cross denied coverage for almost $100,000 in charges for my husband's chemotheraphy with Avastin. After months of battles and many hours of stress and work, that denial was overturned.

Now, Blue Cross/Anthem has denied (retrospectively) coverage for a blood test my husband has (routinely) once a month. The test is called an Immunoassay For Tumor Antigen, Quantitative; CA 19-9 test (procedure 86301).

While the amount of money (approximately $900 per year) isn't huge (like the Avastin bills were), the denial of a routine test that my husband's oncologist feels is necessary is troubling.

I confess that I am worn out from battling Blue Cross. I would like to enjoy my husband's improved health absent battles with his insurance company.

And, I worry that Blue Cross/Anthem has caused our oncologist so much grief that he might elect to decline Blue Cross/Anthem patients. That was the case with the surgeon we used for my husband's most recent surgery; he previously accepted Blue Cross PPO coverage but dropped out of that system after repeated problems with that company.

Has anyone else had this experience? Do your carriers cover this test? Do you have any advice?

Thank you in advance for any information you can give me on this issue.

Hatshepsut

Comments

  • shmurciakova
    shmurciakova Member Posts: 906 Member
    #2
    Perhaps it is Anthem that is the problem? I have Blue Cross and I have never had any problems with them. Mind you, I have never been on Avastin and I also haven't had the CA 19-9 test. I have my CEA drawn periodically though and they have never denied that one. It is a tumor marker for colon cancer. Honestly, I am not sure what the CA 19-9 looks at, but if your doctor wants it then I would think he should be able to order it for your husband! I don't know if Blue Cross coverage varies from state to state, but I have PPO as well. Hmmmm. I am sorry for all your hassles! I would have a heart attack if they said they were not going to cover 100K in bills! You poor thing, at least you got that straightened out.
    I don't really know what to tell you.
    -Susan H.
  • PGLGreg
    PGLGreg Member Posts: 731
    #3
    Though it's not likely, it's worth considering the possibility that it's just a mistake. I had a $360 diagnostic procedure denied because someone in my doctor's office or the path lab mistakenly characterized it as "screening", which my insurance doesn't cover. Once I got secretaries at the lab and my doctor's together, they ganged up on the insurer's secretary.
    -greg
  • Hatshepsut
    Hatshepsut Member Posts: 336 Member
    #4
    PGLGreg said:

    Though it's not likely, it's worth considering the possibility that it's just a mistake. I had a $360 diagnostic procedure denied because someone in my doctor's office or the path lab mistakenly characterized it as "screening", which my insurance doesn't cover. Once I got secretaries at the lab and my doctor's together, they ganged up on the insurer's secretary.
    -greg

    Greg:
    I have confirmed that this is not a mistake.

    Hatshepsut
  • Hatshepsut
    Hatshepsut Member Posts: 336 Member
    #5
    shmurciakova said:

    Perhaps it is Anthem that is the problem? I have Blue Cross and I have never had any problems with them. Mind you, I have never been on Avastin and I also haven't had the CA 19-9 test. I have my CEA drawn periodically though and they have never denied that one. It is a tumor marker for colon cancer. Honestly, I am not sure what the CA 19-9 looks at, but if your doctor wants it then I would think he should be able to order it for your husband! I don't know if Blue Cross coverage varies from state to state, but I have PPO as well. Hmmmm. I am sorry for all your hassles! I would have a heart attack if they said they were not going to cover 100K in bills! You poor thing, at least you got that straightened out.
    I don't really know what to tell you.
    -Susan H.

    Susan: Thank you for your reply. Blue Cross and Anthem are one in the same company. Blue Cross is changing its name to Anthem/Blue Cross here in California. I don't know if the name change is nation-wide but it may be.

    Hatshepsut
  • katienavs
    katienavs Member Posts: 88 Member
    #6
    Hatshepsut,
    I don't have advice but I wanted to tell you how sorry I am you are going through this. I had blue cross coverage when I was diagnosed with stage iv colorectal cancer in June 2006 at the age of 24. I was on a short term six month plan until I was supposed to start work in August. They said it was a preexisting condition and tried to deny covering anything!!!
    It was so unbelievably awful to have to fight an insurance company at the same time dealing with a stage iv diagnosis. It was very deflating and degrading to have to argue and justify that I had no idea I had cancer when I signed up for insurance.
    Whenever a friend or family member or coworker discusses which insurance company to go with I unequivocally tell them to never ever ever go with Blue Cross.
    I know this wasn't advice and probably no help but I wanted to let you know you aren't alone with this struggle. I did have one oncologist order that test but my other two medical oncologists have only ordered the CEA.
    Good luck and hang in there!
    Katie
  • Hanac
    Hanac Member Posts: 55
    #7
    Hi,

    Try the Cancer Legal Resource Center at (866) 843-2572. They have a hotline that can help you with insurance issues.

    Blue Cross initially gave me a hard time about Avastin as well.

    Hana
  • AuthorUnknown
    AuthorUnknown Member Posts: 1,537 Member
    #8
    I am so sorry to hear of your problem. We have Blue Cross and have never had a problem. I added DH to my policy during an open enrollment with my employer. Although DH was already on chemo, they picked up all the tab. They have paid for all chemo including Avastin, Erbitux and Xeloda. It is my understanding that it is not a particular company that gives the problem but problems arrise based on your policy that you have. Although we have Blue Cross and so does our son, we do not have the same benefits or out of pocket expenses. It may be your policy rather than the carrier.
    I would, however, contact whatever agency oversees insurane in your state. Good luck and congratulations on the good medical reports.
  • TY2HC
    TY2HC Member Posts: 46
    #9
    I just wanted to say that it unfortunate that you have to go through this. When I was diagnosed I was lucky enough to have insurance that covered most of the costs of my procedures. Because of stories like yours, and others, I started website and will be starting a non-profit that will help with situations like yours. Unfortunately, I don't have it started yet! But hearing your story has motivated me even more to get this thing started. Again, I am sorry this is happening to you and your husband. I wish you all the best.

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