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Insurance Coverage for Avastin

Hatshepsut's picture
Hatshepsut
Posts: 340
Joined: Nov 2006

Has anyone faced a problem getting their insurance to cover Avastin? My husband has been receiving it for four months and now our insurance company has notified us they don't think it was "medically necessary." My husband's first pet scan after surgery showed no cancer spread. His second petscan showed additional lymph node involvement and several areas with cancer. After four months with Avastin and Camptosar, his latest petscans and ct scans show a major improvement. It sounds "medically necessary" to me!

I've never filed an insurance appeal, but it appears we will do that this time. Any ideas you have are welcome.

Hatshepsut

hopefulone
Posts: 1048
Joined: Jan 2007

Speak with your husbands oncologist about filing the appeal. If they believe he should continue to have the Avastin, they can file appeal on his behalf. Good luck & God Bless. Am glad his scans and pet showed a big improvement. Sounds like medically necessary to me also .

goldfinch's picture
goldfinch
Posts: 737
Joined: Oct 2003

This is your oncologist's job. Talk to him/her. They deemed it medically necessary or they wouldn't have used it. They will be able to support the need. File an appeal. I can't believe an insurance company would wait til now to tell you. Actually, I'm a nurse who deals with insurance companies quite often. Unfortuantely, I do believe they would wait this long. They do this sort of thing too often. Your oncologist should be able to clear it up.
Mary

Betsydoglover's picture
Betsydoglover
Posts: 1255
Joined: Jul 2005

Hi -

I never had any problem with insurance company with Avastin, but they have done plenty of foot dragging on PET scans - still in the end my radiologist gives them a "statement of medical necessity" for the PET scan and they go ahead and pay. Your oncologist should be able to do the same with respect to Avastin treatments for your husband. (Did they actually totally reject the claim or just say they need a statement of medical necessity? At least with my insurance - CIGNA - if they request a medical statement, the claim shows on their web site as "rejected", but when you look at the lower level details, you find that is is "just" pending statment of necessity.

It's a game the insurance companies play to delay payment - I hate it - I think my radiologist may hate it even more - but in my experience it is a game that always resolves ok.

Good luck,
Betsy

greg-k
Posts: 4
Joined: Feb 2007

I had 12 treatments with Avasin over 6 months - together with oxaliplatin - after a right hemi op. Then my oncologist followed up with Avastin by itself for another 12 treatments. My oncologist requested a pre-authorization from Blue Shield - and insurance paid for the ist 12 without delay. For the next series - ins. delayed pmnt for about 6 months - but finally paid everything through the end of the last year based on my onc's statement of medical necessity. To complicate matters - I changed carriers to Aetna in January - they sent a letter stating that pre-authorization for Avastin is not necessary(we had asked for pre-authorization). However, Aetna has not paid the last 5 treatements yet - but I expect them to do so. I had lymph node involvement stage 3. Apparently, the oncologist's statement of medical necessity, i.e., lymph node involvement is critical to ensure payment, as I think Avastin was initially approved for stage 4. Avastin has a good web site which may have useful info for you. Avastin is very expensive, so its easy to see why insurance carriers woulb be reluctant to pay for it. Hope this helps - good luck. I have has clean cts and pet scans throughout treatment and my oncologist highly recommended the additional 12 Avastin treatments.

GregK

KathiM's picture
KathiM
Posts: 8077
Joined: Aug 2005

Wasn't on Avastin, but MAN did I have insurance fights!!!!! I have an HMO, and, forgive me, I wanted to have my bowel resection done by one of the top docs out in the West...BUT, he was not "in my group". I just kept bugging them, and threatened the Insurance Commission.
I got my way, and my resection, and no colostomy.

Whew! It WAS a fight. I agree will others...talk to his onc...they should at least be able to write a statement...
sigh....not only do we have to fight the beast, but the also the people that should be on our side!!!!

Hugs, Kathi

Hatshepsut's picture
Hatshepsut
Posts: 340
Joined: Nov 2006

Thanks to everyone for your input.

Understanding the behavior of insurance carriers can be scary....particularly when you are dealing with drugs that cost thousands of dollars per infusion.

In answer to a couple of questions posed in your answers:

1. Yes. It was an outright rejection not a "pending" response.

2. I'm dealing with Blue Cross.

I would appreciate the further insights of those of you who have posted or the insights of others on this board as well. I need a quick education in what to do (and not do) in filing an appeal.

Hatshepsut

greg-k
Posts: 4
Joined: Feb 2007

I looked up the provider section on Avastin.com and there is a 'reimbursement' section where the drug manufacturer offers a SPOC (single point of contact) program for the oncologist and they offer consulting on appeals and coverage denials. Blue Shield requests a pre-authorization for Avastin, Aetna does not require it - although both companies wanted a 'statement of medical necessity.' Not sure about Blue Cross. I would have your oncologist file an immediate appeal. One of my various claims with Blue Shield not Avastin related was for reimbusement for Procrit. The carrier initially denied payment based on their standard for medical necessity which required a hemoglobin count of less than 12. They actually sent a letter stating so, notwithstanding the fact that in each claim the lab report documented that the count was in fact less that 12. My oncologist appealed but I was so angry when I realized that they had sat on the claims for 120+ days, that I called and complained to the medical director (all carriers have one0, and a week later - without further comment - they paid. You should be able to track your claim online. The carrier posts the turnaround time for each claim. Of interest, when a claim is sent back for 'additional information' the clock stops. In my case, the 120+ days delay do not show up as part of the turnaround time - these claims were paid as 'ajustments' - this probably has more to do with the efficiency reports they are required to keep and disclose. In your case I think they want that statement of medical necessity in order to consider reimbursement. Your oncologist will know the exact parameters for the approved Avastin protocols. If you are in a grey area - just remember that I was in the same boat - and at least one carrier - Blue Shield - has paid!

Hope this helps.

Gregk

mwomack
Posts: 78
Joined: Jan 2005

I would guess that a call from the onc. would be enough. We have not had drugs refused, but every Pet scan has been denied up front and was then approved with a call from the onc.

Is your husband classified as Stage III because I don't think it has been approved for Stage III yet (in trials). But in the case of a recurrence or continuing disease it would be approved.
MA

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