When Prostate Cancer Returns – The Insurance Company Two-Step – Part 7

Getting a straight answer from an insurance company – well that is like asking the Government to simply explain the Tax Code or the Affordable Care Act – it’s impossible!  And impossible leads to frustration.  The saga continues…

Health InsuranceFor those who have been following – I am on one had a prostate cancer survivor – on the other, it appears that prostate cancer has reared its ugly head again and my challenge is getting the treatment that I want with the blessing of my health insurance company.  Now mind you, the treatment I want is FDA approved and offered at the Mayo Clinic in Rocherster, MN.  So the question should be – why is this so hard?

APPROVAL VS APPEAL

The process should be simple!  Doctors says “You need this.”  You get it done and the health insurance company pays.  Simple right?  Not so fast.  It appears that the health insurance companies distrust the doctors so in order for the health insurance company to pay one must get preapproval.  As I asked in my last entry – “Who made Health Insurance Companies God?”

OK…I’ll play by the rules.  So, in my case, in contact with the Mayo Clinic, the request was sent for the one thing that can isolate where my prostate cancer growth is originating and thereby help me have an effective treatment – a C-11 Pet Scan.  Thanks to the folks at the Mayo Clinic who have to put up with this never ending bull shit.

Answer back – DENIED!

What next?  Well the C-11 Pet Scan – so says National Imaging which does the pre-approval screening for Blue Cross/Blue Shield of SC – was not medically necessary.  What?

They approved a bone scan and CT scan which was destined to show nothing, but the one scan that can show where the new cancer is embedded is denied.  I don’t know about you, but that’s the damn dumbest thing I’ve ever heard.  But there has to be a solution.

NEXT STEPS

Nothing being one to give up (which is likely what the insurance company would like me to do), I went on the BC/BS website to seek information on how I could appeal their decision.  Guess what…nothing there that answers that question.  Amazing?  Na…they don’t want people to appeal.  Rather, my guess is they would rather us (the patient) just take their finding as God and quit.

Not a chance!

Web based connection to BC/BS and the question is raised about appealing the decision.

Instant email in return indicating that I would get a call within 1 to 3 business days.

Sure enough I got the call.  Pleasant lady on the other end tells me that I can’t appeal since I had not submitted a claim for service.  Duh!!!  Of course I didn’t.  I didn’t get that far.  I tell the nice lady that the preapproval process is where the failure occurred and that is what I need to appeal.

“Oh,” she responds, “well you’ll have to take that up with National Imaging, we can’t help you.”

“How might I go about doing that,” I asked.

“Oh…your doctor will have to talk with them.  They don’t deal with patients.”

Let me get this – BC/BS can’t talk with me since I tried to follow the rules and National Imaging can’t talk with me because I’m not a doctor.  I am sure that those who follow understand how this is crazy making for a consumer just wanting to get appropriate treatment.

WHERE FROM HERE?

Not being a person to give up…looks like on Monday I’ll be calling the Mayo Clinic and see if they can help by giving National Imaging more of the information they need to get the test approved.

Sad, but this should not be such a stressful process.

YOUR COMMENTS ARE WELCOME

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