When Prostate Cancer Returns – The Mayo Clinic Process Continues – Part 5

Not only is it disconcerting to find out that you have recurring prostate cancer, but then to have to deal with restrictive insurance companies and find out that it will only get worse, just adds icing to the cake of worry and stress.  The bright spot – dealing with the Mayo Clinic.

So here’s the deal.  You find you have a rising PSA when, without a prostate, your PSA should be zero.  Problem!

You then find that there is a wonderful test that potentially could identify where the growing prostate cancer is located so that appropriate treatment could take place.  Get the test!  Right?  Not so fast…

In the Mayo Clinic consult I find that in order for insurance to cover the test, they require other tests – CAT scan and Bone Scan – be done so that (my words – less expensive diagnostic tests) one can find out if there is a “cheaper” way to determine where the problem is.  At a simple level that makes some since, but reality and bureaucracy don’t often mix.

Starting cheap and controlling costs is the insurance company’s way of creating profit.  But at what cost?  My health?

Reality is – the only test that has a chance of detecting where my recurring prostate cancer is originating is the Cholene C-11 Pet Scan.  With a low level PSA (1.1) the chance a CAT Scan or Bone Scan will show anything is slim to none.  Ah, hell…None!  So…the ONLY option is the C-11 Pet Scan.  Now doesn’t it make sense that someone with some fundamental intelligence would look at the facts and circumstances and just order the C-11 Pet Scan from the get go?

The insurance approach has done nothing but waste money.  Start cheap and then (potentially) approve the one test that would work.  Arrrrg!

INSURANCE SOAP BOX TIME

But it gets worse – and yes now I am on my soap box.

So…knowing my insurance will change at the end of December 2013, I go to Blue Cross Blue Shield of SC to inquire about the “gold” plan for South Carolina residents for 2014.  What a eye opener.  First, they calculate the monthly cost which is high, but in this day and age that is expected.  So far no surprises.

Then I ask – what is covered and for how much?  That’s when it starts to get interesting.  I am told the deductibles and out of pocket expenses.  When it’s all said and done I’d be out of pocket $4,200 plus the monthly cost.  OK…not bad.  But wait there’s more.

So I ask, where are these insurance benefits available?  “You mean who can provide them,” asked the Blue Cross representative.  “Yes.”  Now dumb me, I figure that if you have the “Gold Plan” you should be able to get benefits anywhere.  WRONG!

I’m told that coverage is only available through providers in the network.  STOP!  Really?  Then the BC/BS representative said we’ve just added the Greenville, SC Hospital System.  I used to just be St. Francis.

I was blown away.  You mean to tell me that if I don’t choose a provider in your network, I have to pay for services out of pocket?  The response from BS/BS – YES!

Pardon the way I put this, but WTF?

I proceeded to ask, “So if I had a brain tumor and the #1 brain surgeon was at MD Anderson and they are not in the SC BC/BS network, I would either have to choose Dr. Nimrod or pay out of pocket for the best care?”  “Yes, that’s correct!”

OMG…if that’s what we have to look forward to with the Affordable Care Act then God help us.

BACK TO A MORE COMFORTABLE REALITY

Thank God for people that know how to navigate this mess.  Back to simplicity.  I email through the Mayo Clinic system to find out next steps and was provided the phone number for those (blessed) folks who get pre-approval for people like me who need the help and are pissed with insurance companies (who made them the decision makes for my health?).  I simply called the Mayo Clinic – got a lovely lady on the phone who was interested in helping me.  She listened to my story, found the CPT code, got my insurance information and is proceeding today to be my advocate with my current insurance provider.

The C-11 Pet scan is scheduled and the journey continues to health…