When Prostate Cancer Returns – Between a Rock and a Hard Place with Health Insurance – Part 10

Last entry (Part 9) Mayo Clinic fumbles the preverbial ball – but what an awesome recovery!  Now we get the full picture and to be clear the process will be shared since the issue is NOT the Mayo Clinic, but obstinate Health Insurance Companies that seem to think they know more than my doctor.  Arrrgggg!!!

My last entry is here: https://chuckgallagher.wordpress.com/2013/11/27/when-prostate-cancer-returns-ouch-mayo-clinic-fumbles-the-ball-part-9/

NEWS on the MAYO FRONT!

Mayo Clinic LogoToday I get an inpatient email from the Mayo Clinic  that stated the following:

Your PSA is still 1.1–which is a good thing that it’s not moving anywhere quickly. Per Dr. Kwon I have placed orders for a prostate MRI and a return with Dr. Kwon. If you get the C11 PET approved through your insurance, please let me know and I will also order that scan for you.

To which I responded:

Diane (Dr Kwon’s nurse)…thank you for your email. It seems I am stuck between two competing factors – National Imaging Associates and the Mayo Clinic Urology. I cannot get my insurance company BC/BS to approved the C-11 that pre-certification comes through National Imaging Association. They won’t approved without a peer-to-peer discussion. Mayo Urology won’t do a peer-to-peer. PATIENT IS CAUGHT IN THE MIDDLE. Seems that sucks for the Patient (me in this case). Therefore, I respectfully request that someone with clinical knowledge do the peer-to-peer so that the C-11 can be approved. We both know that a pelvic MRI is likely (with a PSA of 1.1) to show nothing just like the CT scan and Bone scan. Happy to have the MRI done, but if that improves the approval of the C-11 scan great…otherwise seems it is a waste of time. National Imaging Association won’t consider a new application for the C-11 – they (according to your pre-certification dept) are only willing to reconsider with a peer-to-peer. I DO UNDERSTAND the time associated with this request. However, if it were you or your husband and there seems to be a stand off taking place that holds the patient (me) from getting what we both know I need, I’m sure you would agree that I have to ask. I am not asking that Dr. Kwon do the peer-to-peer, but do believe that there is someone in urology that is capable of convincing the physicial (likely retired and sitting on his ass with National Imaging Association) with NIA that a C-11 is the only thing that is likely to identify the location of my recurrent Prostate Cancer so that an effective treatment can be administered. I really appreciate your willingness to consider my request and hope that it falls on willing ears. Honestly that would be the best Holiday Gift I could receive – a yes from NIA. Thanks and hope your Thanksgiving was a blessing. Chuck

There is a simple saying – “You’ll always miss 100% of the shots you don’t take!”  In other words you can’t get a “Yes” without asking.  Me…well I am all about asking and more than once!  Sales motto – ask until you get a “Yes” of piss them off trying.  Either way you’ll get the outcome you desire or know that you’ve done your best trying!

Then later today a Mayo Clinic response – BETTER THAN EXPECTED!

Dr. Kwon will do a peer to peer review. Just call our pre-certification office to set it up at XXX-XXX-XXXX.

Oh my…certainly better than expected.  Dr. Kwon is the man when it comes to C-11 Pet Scans…so if anyone can convince National Imaging Associates of the value to me, he is the one that can do that!!!

THANK YOU!  And the process continues!

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4 Responses to When Prostate Cancer Returns – Between a Rock and a Hard Place with Health Insurance – Part 10

  1. Jack Wagner says:

    We need an update Chuck ~ we are also seeing Dr.Kwon!

  2. David Sharon says:

    YES ~ PLEASE update us at to your experience with Mayo following peer-to-peer review? What is your current status? We will be seeing Dr. Kwon in Sept. 2014!

    • Mayo was willing to do peer-to-peer but the insurance numskulls weren’t. BC/BS ultimately denied the opportunity to work with the fine folks at the Mayo. I elected to have IMRT radiation and it seems to be working quite well with a dramatic quick reduction in my PSA.

      • David Sharon says:

        Chuck – Unfortunate that insurance companies are allowed to make medical decisions regarding our health and welfare! Medicare and Humana will allow the C11 but their is no assurance they will pay for it! I will proceed and have it and see what happens. Hope IMRT is the answer for you! Best of luck

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