Deemed medically unnecessary by Insurance

1 Healthy Bob
1 Healthy Bob Member Posts: 10 Member
in Head and Neck Cancer #1

One year and one month ago I had nasopharyngeal tonsil cancer removed along with 39 lymph nodes and two glof ball sized neck masses. I chose unconventional treatments against Dr's orders. At my 3 month PET scan all looked great, surprised the doctor with energy and activity. All following visual inspections at the oncologogist, still looking and feeling great! Very limited carbs and vegitarian lost 65lbs in 4 months, best bloodwork in my 49 years of life. Ath the One Year PET scan date... ... Deemed medically unnecessay by SealedBCBS - Michigan. An order of CT scan was placed by oncologyst after one-on-one with care management department, again deemed medically unnecessary. The services are covered by my medical insurance plan! Why is it deemed medically unnecessary? Am I too healthy? Not profitable enough for the medical machine?

Comments

  • soonermom
    soonermom Member Posts: 155
    edited July 2017 #2
    Don't Get Me Started

    We have been through the same thing.  The only thing that made a difference in some instances was if the physician did a live call into the medical director of the insurance company.  

  • caregiver wife
    caregiver wife Member Posts: 234
    #3
    Coverage denied

    Did you receive a denial of coverage letter from BCBS??  I would expect you to receive such a letter with an explanation for their denial.

    Did you call the care management department yourself?  I have had great success with case management nurse with my own insurance company.

    What did your oncologist say after the denial?  Are they persuing the issue with the insurance company?

    Finally, all coverage denials can be challenged.  Michigan dept of ins may be able to assist you with how to procede.                                                                   http://www.michigan.gov/difs/

    Hope this is helpful,

    Crystal

     

  • CivilMatt
    CivilMatt Member Posts: 4,722 Member
    #4
    welcome

    1 H Bob,

    Welcome to the H&N forum.  What is unconventional treatments?

    Matt

  • 1 Healthy Bob
    1 Healthy Bob Member Posts: 10 Member
    #5
    soonermom said:

    Don't Get Me Started

    We have been through the same thing.  The only thing that made a difference in some instances was if the physician did a live call into the medical director of the insurance company.  

    Peer to Peer

    Both my oncologist and primary care physicians had a peer to peer conversation with the uptight case Dr at the Insurance company. Both PET and CT deemed medically unnecessary

  • 1 Healthy Bob
    1 Healthy Bob Member Posts: 10 Member
    #6
    caregiver wife said:

    Coverage denied

    Did you receive a denial of coverage letter from BCBS??  I would expect you to receive such a letter with an explanation for their denial.

    Did you call the care management department yourself?  I have had great success with case management nurse with my own insurance company.

    What did your oncologist say after the denial?  Are they persuing the issue with the insurance company?

    Finally, all coverage denials can be challenged.  Michigan dept of ins may be able to assist you with how to procede.                                                                   http://www.michigan.gov/difs/

    Hope this is helpful,

    Crystal

     

    Peer to peer Coverage Denied

    I did speak with insurance representative. They insisted that my primary care or oncologist call for a peer to peer with their subcontractor. No change in their decision. I did not get a letter from BCBS of Michigan. The insurance rep even told me that the PET and CT are covered as part of my plan!

    Thank you

  • 1 Healthy Bob
    1 Healthy Bob Member Posts: 10 Member
    #7
    Semi Success CT approved

    After calling BCBS and talking with the representative to getting and forwarding details to my oncologyst. The previous Deemed Not Medically Necessary has been approved. Update pending results of the scan. Thank you for the advise in getting this resolved.

  • caregiver wife
    caregiver wife Member Posts: 234
    edited July 2017 #8
    CT approved

    Great news!

  • tommyodavey
    tommyodavey Member Posts: 726 Member
    #9
    Good To Hear

    That is great it finally got approved.  My surgeon told me that BCBS always denies a PET scan unless he writes down he suspects the cancer has returned.  Yes, he lies and it gets approved.  What a system!

    But now, after having 3 scans, they won't approve another one for 4 years or unless he sees something suspicious.  So I continue to see him once a year which is fine by me.

    The test must be one of the most expensive ones out there.  What other reason would it be for it to commonly be denied not only by BCBS but by all the other insurance companies too?  Who cares now.  You're getting it and that is fantastic news.  Hopefully it won't show anything really bad.  It is a great test to have though.  It shows your heart valves, stomach problems, etc., or anything else that is wrong with you.  Because of my PET scans I finally got a sinus infection treated the right way.  The infection had been an ongoing problem for over a year until the scan showed exactly what was wrong.  Two birds with one stone per say.  It also said my heart plaque was normal for a man of my age.  Good to hear!  Read the whole report when you get a copy and you'll see how comprehensive it is.

  • 1 Healthy Bob
    1 Healthy Bob Member Posts: 10 Member
    edited July 2017 #10
    caregiver wife said:

    CT approved

    Great news!

    CT Results are in!

    Examination: CT SOFT TISSUE NECK WITH CONTRAST WITH OR W/O 2D RECON

    Date: 7/21/2017 7:25 AM

    History: 49 y.o. male with a pT2N3M0 Stage IVB squamous cell carcinoma
    of the oropharynx (left tonsil), p16 negative, who underwent a left
    transoral robotic assisted radical left tonsillectomy, right
    tonsillectomy, and left selective neck dissection on 6/6/16

    Comparison: CT soft tissue neck 05/07/2016, PET/CT of the head and
    neck 09/07/2016.

    Technique:

    CT of the soft tissues of neck was obtained in axial plane after
    intravenous injection of 75 mL of contrast material(Isovue 300).
    Coronal and sagittal reformatted images were obtained from the axial
    views for evaluation of soft tissues of neck in sagittal and coronal
    planes.

    Findings:

    There is no evidence of residual or recurrent tumor in the tonsillar
    regions bilaterally.

    The enhancing 1.3 cm level 2 lymph node on the right side is stable in
    size.

    There is no evidence of pathologic lymphadenopathy in neck.

    No new lesions have appeared in the interval..

    Sagittal and coronal images confirm above findings.

    IMPRESSION:

    No evidence of residual or recurrent disease.

  • caregiver wife
    caregiver wife Member Posts: 234
    #11
    No evidence of residual or recurrent disease.

    Wonderful!!!

  • 1 Healthy Bob
    1 Healthy Bob Member Posts: 10 Member
    edited July 2017 #12
    CivilMatt said:

    welcome

    1 H Bob,

    Welcome to the H&N forum.  What is unconventional treatments?

    Matt

    Unconventional treatments

    The treatment that I called unconventional is only that to the medical field. It isn't the prescribed course of treatment, (Cut, Burn, Poison), by the AMA. I use a holistic care approach with a ketogenic diet.

    I did have robotic surgery for the removal of my tonsils and surrounding tissue. About two week recovery time. Had we known now back before surgery we may have let a healthy life style correct the issue.

    This information was researched by my wife. My treatment through the course of the first 4 months. Maintenance continuing.

    My holistic Doc is Dr.Robert Grafton - PSI Medical in Wixom and Rochester, MI

    He has a shared office in Grand Rapids, MI - Holistic Care Approach

    Treatment

    Maintenance

     

     

    Ascorbic Acid (Vitamin C)

    120,000 mg by IV every 7 days.

    Ascorbic Acid (Vitamin C)

    120,000 mg by IV every 14 days.

    Vitamin A 10,000 IU capsule take twice by mouth daily.

    Vitamin A 3000 IU capsule take twice by mouth daily.

    Vitamin E 1600 UNIT capsule Twice daily by mouth.

    Vitamin E 200 UNIT capsule Take 200 Units by mouth daily.

     

     

    Vitamin B complex 50 - 1 tablet twice daily

    Vitamin B complex 50 - 1 tablet twice daily

    Selenium Take 200 mcg by mouth once daily. (methyl selenic acid is best form)

    Selenium Take 100 mcg by mouth once daily.

    Ascorbic acid (VITAMIN C) Take up to 5,000 mg by mouth daily. Active tablet

    Ascorbic acid (VITAMIN C) Take up to 5,000 mg by mouth daily. Active tablet

    Co-enzyme Q-10 200mg capsule by mouth 2 (two) times daily.

    Co-enzyme Q-10 60mg or 100mg capsule by mouth 2 (two) times daily.

    CALM (Magnesium/Calcium brand) 1 TSP 4 times daily in water

    CALM (Magnesium/Calcium brand) 1 TSP 2 times daily in water

    Niacin (NIASPAN) 500 mg CR tablet Take 1 by mouth daily. Non-Flushing preferred.

    Niacin (NIASPAN) 500 mg CR tablet Take 1 by mouth daily. Non-Flushing preferred.

     

     

    Caratinoids – 100mg (1 twice daily)

    Biotin 1 mg tablet Take 1,000 mcg by mouth 3 (three) Active times daily.

    Frankencense oil in lotion rubbed into soles of feet, neck, chest.

    Pure Oil put into veg. capsules 3 times a day (we filled ourselves)

    tastes aweful :)

    Alpha lipoic acid 200 mg Cap Take by mouth. Active

    ---

    NAC (N-Acetyl L-cysteine 250mg

     

     

     

    Methyl-folate 800mcg or more

    Flaxseed oil 2 TSP take by mouth or added to foods.

    Multi-vitamin Take 1 capsule by mouth daily.

    Cannabinoids (Oral dosages)

    https://www.diamondcbd.com/

    Cannabinoids are from hemp no THC.

     

    Medical Marijuana:

    – Indigo Variety to manage pain as needed

    - Sativa for cellular inflammation

    L - Carnitine 150mg

    (15ml twice a day)

     

    Ketogenic Diet for Cancer – Low/No Carbs

    20g-50g/day from veg & fruit

    Book – Fighting Cancer with anti-oxidants (protecting the body from Chemotherapy and Radiation)

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