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Insurance Coverage for Avastin

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

I posted some time ago that our insurer, Blue Cross of California, had (retrospectively) denied coverage for Avastin chemotherapy my husband has had for stage four colon cancer. A number of you were kind enough to post responses that were generally supportive and encouraged me that that everything would work out. Our oncologist filed an appeal with our insurance company (in March 2007) and Blue Cross has finally responded that they are denying the claim again. The original denial was made because the Blue Cross doctor claimed that my husband has stage three colon cancer (I wish!!).Our oncologist says he has stage four. The latest denial came down today and so far, Blue Cross will not give me a reason for the second denial. Has anyone had a similar experience? Does anyone have advice? My husband was treated for a period of months with Avastin and Camptosar. He is now in remission. His Avastin bills are substantial. I am aware that the drug manufacturer offers some financial support but, from what I read on the Internet, we fall just outside the financial qualifications for that help.

Thanks.

Hatshepsut

AuthorUnknown
Posts: 1560
Joined: May 2006

Call the insurance and ask for a reason for denial. Ask to speak to the manager. When you know the reason, you can proceed accordingly.

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

I have called the insurer, Blue Cross of California, every day (sometimes several times a day) for weeks. Believe me, I have asked for a reason and today they told me it was too soon for that information to be available although they did decide to deny our appeal effective today. In fact, I just called them again before pulling up this site. We plan to file a complaint with the state insurance board but I would appreciate knowing any other possible strategies.

Hatshepsut

AuthorUnknown
Posts: 1560
Joined: May 2006

Demand to speak to the manager. They must tell you the reason for denial. It would be easier for you then to file a complaint with the state insurance board. They most likely will ask for a reason for denial.

I am very sorry you have to go through this.

chynabear's picture
chynabear
Posts: 483
Joined: Jul 2005

I have Blue Cross Blue Shield of Illinois and they denied a PET scan (a year after they approved it) and a PET/CT (shortly after they stated, "no approval needed"). When they FINALLY got around to sending me a reason for denial, we noticed that they were using very outdated materials from 2002 (the denials came in 2005). My doctors appealed twice and again I was denied twice.

It took my father-in-law and I to write our own letter stating a few obvious facts, including the outdated information they insisted on using and the fact that they had either approved the procedure or stated no approval needed. They approved it and finally paid.

You might have to take the appeal into your own hands once you finally get a reason for denial.

Also, my dentist has mentioned people who have called the insurance company EVERY SINGLE DAY begging for approval. He believes that the insurance companies sometimes approves stuff just to shut the person up. Might work, who knows. In any case, keep your head up and keep fighting it. Just watch for outdated statistics and information on their part and you'll be able to come up with a decent letter on your own.

Good luck to you. I know it took me around 6 months or more to finally win the appeal.

Tricia

KierstenRx's picture
KierstenRx
Posts: 249
Joined: Nov 2006

I just found out my last treatment that my Avastin could not get approval because I am stage three and not four. I have had four treatments with it and I just about crapped. However, my oncologist said I would never see a bill, it was his problem and he would contact the drug company. He said he wanted me on Avastin and I was going to get it. I knew I have a wonderful oncologist, but I never knew how great he is until now. Anyway, maybe you could see if your oncologist could contact the drug company to see if they would provide the medicine. Best of luck and I will keep you in my thoughts.

Kiersten

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

Again, thank you for your encouragement. This has been a particularly stressful day.

Tonight, I reached a customer service representative who told me the denial of all charges relating to Avastin was made by Blue Cross because the doctor did not administer a drug she called 5FU concurrently with the Avastin. (My husband received camptosar with the Avastin.) Because of that omission, she told me Blue Cross was denying the claim because the Avastin treatment was classified as "investigational."

Hatshepsut

Hanacallaghan
Posts: 4
Joined: Jun 2007

Hi,

Perhaps your Onc can get your husband on the study. Then Genentech pays for the Avastin. Check out the NIH website to see if there is a study that fits.

Good Luck,

Hana

P.S. I had Blue Cross of California too. They routinely denied everything first time around. Blue Cross is governed by the California Agency that regulates HMOs. The Agency has an 800 number that was helpful. I'm off to work now, but will try to dig the number up.

houseofclay
Posts: 63
Joined: Nov 2004

I have two suggestions. First, if the reason for the denial is that 5FU was not administered with the Avastin, I would call the oncologist's office to see if they can argue with the insurance company. The office would be aware of the reimbursement rules and if they made the mistake, you should not pay for it. Second, Genentech has a program, Single Point of Contact, that helps with situations such as yours. Your doctor, however, would have to be the party to contact the service.

Since it seems like your doctor caused the problem to begin with, having the doctor find the solution seems like an option worth exploring.

vinny3's picture
vinny3
Posts: 933
Joined: Jun 2006

Unfortunately I suspect the insurance company will keep denying until enough pressure is put on it. Besides checking with the insurance commission for your state you may try contacting your congressman. With stage 4 there is ample evidence for the use of Avastin no matter what other drugs are used.

Dick

Hanac
Posts: 55
Joined: May 2007

Hi again,

Blue Cross is regulated by the Department of Managed Health Care in California. Check out www.dmhc.ca.gov . The consumer complaint line is 1-888-466-2219.

Good Luck,

Hana

AuthorUnknown
Posts: 1560
Joined: May 2006

You keep fighting the insurance company. I, too, have BCBS (Alabama). To date, they have not denied any claim including Avastin (twice).

They are now paying for Xeloda. I know we have cost them a lot of money in the last two years, but that is why you buy insurance.

With the price of Avastin (and other drugs), this situation is scary. Continue your determined fight with them. Maybe your onc has a nurse or office manager good with insurance. I am sure they deal with this regular. This is not some experimental drug and they know it.

You are doing a great job. Keep us posted.

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

Thank you to everyone for their posts and support. I am not by nature an aggressive person, but Blue Cross is teaching me that skill!

I will continue to challenge Blue Cross on this denial and would appreciate knowing if anyone else has had Avastin without 5FU and I would obviously like to know if your treatments have been covered by insurance (by Blue Cross or any other insurance carrier).

This is a serious matter for us. Not only is the amount of money large but Blue Cross' denial challenges one's confidence in the treatment protocol recommended by one's doctor. We believe in our doctor 1000 percent. We believe that is part of recovery. Why should one's recovery be compromised by an insurance company for the sake of profit?

Hatshepsut

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