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Insurance Considers Rituxan for Cancer to be under study?

PeprmntPat55's picture
PeprmntPat55
Posts: 64
Joined: Aug 2016

Just received first EOB in the mail for Day 1, Rituxan therapy.  They have 'rejected' payment stating that it is not generally accepted treatment or experimental?  

I am floored. Of course, it's Saturday and I can't speak to anyone until Monday.  The total amount I owe provider column is $6005.00.  

Holy ****!  Has anyone else experienced this?  

I have NHFL, grade 1 stage 3B.  

PP55

Anonymous user (not verified)

CIGNA paid for my twenty-some infusions. Ask for clarifications.

PeprmntPat55's picture
PeprmntPat55
Posts: 64
Joined: Aug 2016

Thanks GKH.  I will come Monday!

yesyes2
Posts: 592
Joined: Jul 2009

PeprmntPat55 I am so sorry on top of everything else you are having to deal with the insurance company.  Rituxan has been being used for the treatment of Lymphoma for atleast the past 16 years.  I've been getting it since Jan 2008 and have never run into a problem with payment, over 30 infusions and counting.  I would first check with insurance and than contact your doctor or infusion center.  There may be a coding error causing confusion.  Point out to them that if it's still an experiment why has it just this year gone to being made generically.  It is used for many forms of autoimmune diseases but was first used for Lymphoma (yr 2000) and the literature documents survival has greatly increased since the application of this drug.  BTW, my hospital charges $25,000 per infusion.  Although insurance does not pay that much and the hospital than adjusts the charges.

Rocquie's picture
Rocquie
Posts: 857
Joined: Mar 2013

Pat, I'm so sorry this shock has come right at the weekend when you feel helpless to do anything about it!  It will be worked out--I promise, so please try to rest and recover and not worry about it. 

My insurance company is under contract with providers. It is the provider's responsibility to get pre-approval on all services. If they fail to do that, the patient cannot be held responsible for the charges. I cannot imagine a healthcare facility accepting insurance assignments without a contract. 

Recently, I showed up for a CT scan when I was informed the insurance has declined payment. I was so surprised because nothing has ever been declined. (I did not get the scan). The reason was their protocal was CT scans could be repeated in 6 months and it had only been 4 months. All it took was a call from my Doctor explaining why it was medically necessary and it was approved. 

Your clinic's insurance specialists will get it worked out. 

All 20 of my Rituxan infusions were completely covered. 

I hope your first infusion went well and was well tolerated. How are you feeling, aside from the financial worry? I hope you enjoy the rest of your weekend.

Hugs,

Rocquie

 

Max Former Hodg...
Posts: 3690
Joined: May 2012

Patty,

The refusal to pay for Rituxan is ridiculous.  Rituxan is often refused for HL, but that is because only one rare strain of HL has CD-20 cells, which is what Rituxan kills (I had that rare strain of HL, and did receive Rituxan).

Helath Insurance is in a quagmire right now, with many companies going out of business.  It is the duty of your doctor to appeal this and hopefully get a reveral of the carrier's decision.

max

PeprmntPat55's picture
PeprmntPat55
Posts: 64
Joined: Aug 2016

Thank you all for your very helpful responses.  I have the paperwork confirming that my Dr did get pre-approval for treatment and hearing your responses helps me to feel a little bit better about this.  I am trying not to let it be a dark cloud.  

Rocquie, Day 1 of R & B stopped short halfway through due to reaction.  Day 2 of of Bendamustine went without any problems.  It was so short compared to Day 1.  
Both days I was totally wiped out.  Went home and slept through the night except for getting up to go to the bathroom. Only a tiny bit of nausea and the pills took care of that.  

I actually worked the day after #2 and worked full days the remainder of the week!  I can tell that I'm not up to par but really if this is the worst of it, I feel very fortunate! Thanks for asking.  

I'm so thankful to have this board.  You all have helped me so much already.  

Blessings, 

PP55

 

 

lindary's picture
lindary
Posts: 710
Joined: Mar 2015

First insurnace. I learned years ago from a co-worker with a premi son who needed constant medical care for almost 10 years. The Drs and therapists would constantly recommend treatments or therapies and the insurnace would reject it. They would refile and it would pass or not. They would refile again and often it was then accepted. She learned though a support group this could be normal. The insurance will reject some claims knowing that some % of people will just pay and not refile. Then there is a % of people who give up wiht the seocn rejection. By the third filing those are the people that probably won't give up until the insurance approves the claim.  

Most of my claims went through the first time. Anytime it didn't I just contact my oncologist's nurse and she took care of it. Because of that co-worker I didn't panic when I saw a bill for $25,000 for a treatment. Never saw another bill for that. 

 

po18guy's picture
po18guy
Posts: 1216
Joined: Nov 2011

First, call the treatment center and have them re-submit/appeal - they do this on a daily basis. If no help, every major city TV station has a citizen help line. Call and expose this old tactic. Get the company publicly embarrassed. Some simply must be embarrassed in order to carry out their legal responsbility. If  you choose to pay for it, the insurance company simply saves $. Check the FDA approval date for Rituxan, and that will put the lie to their claim. Call your member of Congress. Do a web search for "class action suit (company name)" There are many avenues.

PeprmntPat55's picture
PeprmntPat55
Posts: 64
Joined: Aug 2016

LOL!  I needed a good laugh and you gave it to me today!  Thanks ,*)  If and when I call the TV stations, you will be the first to know!

Anonymous user (not verified)

According to people I use this is not unusual. Probably a coding error. May need a new statement from Dr. But they most always pay. A small error on the form submitted can cause this. Stay calm, return fire.

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