<b>Petitioning for Insurance Coverage for Disputed Treatments</b>

&&url are available online.  These are form letters which help you write appeal and other letters to insurance companies when medically necessities are denied.  Useful.  

<b>Denial of Clinical Trial Coverage: </b>

The &&url may be able to help / provide resources for patients with insurance problems, including problems with clinical trial coverage. 
 
<b>A Listmember wrote:
The insurance company rejected claims for treatment for the ET743 Clinical Trial. We had our hearing last night. Even the local oncologists went to the hearing with us! I guess the next step is to appeal at the state level. Does anyone have any other ideas that we could use to get this covered?</b>

1. Take a look at this NIH site titled, &&url

2. If your insurance carrier is already covering clinical trials in other states, they may find it harder to reject your claim. Here's part of a press release from 16 Dec 1999 - more than a year ago - that mentions a number of states requiring insurance coverage. Note, also, the number of major carriers participating. The reason they're doing it is that it's good business - finding better medicines will reduce their overall costs and clinical trials is the only way that new medicines can be evaluated.

<b>PRESS RELEASE</b>
The American Society of Clinical Oncology, representing 14,000 cancer specialists, today called on insurance companies nationwide to immediately follow the lead of companies operating in New Jersey and cover the costs of patient participation in cancer clinical trials.

The news that Oxford Health Plans, Aetna/US Healthcare, Cigna HealthCare and Prudential HealthCare would cover the costs of patients participating in clinical trials for experimental cancer treatments that have been sanctioned by federal health agencies was reported in today's New York Times. 

"It is high time that cancer patients nationwide benefited from promising new therapies offered in clinical trials," said Dr. Joseph S. Bailes, President of ASCO. "These companies should be applauded for recognizing their role in encouraging cancer patients to participate in clinical trials."

"Companies are seeing the writing on the wall. Coverage of cancer trials is seeping into Medicare reform legislation, budget agreements, the Patients' Bill of Rights, and state laws, including those in Maryland, Virginia and Illinois. In addition, the Department of Veterans Affairs, Department of Defense and United HealthCare have all reached agreements to cover cancer clinical trials. This is now a trend, and other insurers and Medicare should sit up and take notice," said Dr. John Durant, ASCO Executive Vice President.


Here's another &&url regarding insurance coverage for clinical trials along with an excerpt from that press release:

<b>PHS Health Plans Extends Coverage to Clinical Cancer Trials</b>
"September 27, 2000, Shelton, CT -- PHS Health Plans will begin covering federally approved clinical cancer trials for its commercial members in Connecticut and New York, effective today. Coverage will now include routine care for cancer patients enrolled in Stage I, II and III clinical cancer trials at health care facilities and physician offices in the PHS Health Plans network."

"To qualify, PHS Health Plans members must be enrolled in a clinical trial that is approved by at least one of the following organizations: The National Institutes of Health (Stage I, II, and III); The United States Food and Drug Administration, in the form of an investigational new drug (IND) exemption (Stage I, II, and III); The United States Department of Defense; or The United States Department of Veterans Affairs."


<b>Denial of Consultations or Treatment at a Sarcoma Center</b>

<b>Another listmember wrote:
Dad is retired from The Company and has an appointment with Dr. Demetri, the insurance company said they would not pay for ANY treatment or office visits...they said they wouldn't even cover surgery</b>

1) Ask your dad get the denial in writing including specifically (citing chapter and verse) why they say it isn't covered.

2) Review the Summary of Coverage booklet that's provided to every employee or retiree and see if the reason for denial matches the summary.

3) Most Summaries of Coverage make reference to the insurance contract between the employer and the insurance company. In most cases the employee or retiree is entitled to request a copy of the insurance contract. If not, then it can probably be reviewed on The Company's premises. Review the contract.

4) Contact The Company's Human Resources (Personnel) Department and see if they agree with the insurance company's interpretation of coverage. If not, they should help your dad get the decision reversed.

5) Was your dad a union man? If so, the union will help him.

6) See if your state's insurance department will help. What state does your dad live in?

7) See if you can get any help from the Patient Advocate Foundation. 

<b>&&url</b>
753 Thimble Shoals Blvd, Suite B, Newport News, VA 23606, Phone: 800-532-5274 Fax: 757-873-8999.

8) Your request for the consultation and/or treatment at a sarcoma center is justified by the medical journal articles that show better survival rates for patients treated at sarcoma centers, as well as the NCCN Guidelines recommending treatment at a sarcoma center.  These should be printed out and attached to all queries, appeals, and requests. &&url


Still another listmember wrote:

Also check with your insurance and with your benefits dept.  <b>LMS is complex enough that often you can ask for, or insist upon, a case manager. </b> Here is a little excerpt from a friend of mine at a national insurance company:

Just wanted to send a few tips on working with your health plan and requesting a case manager.

<b>If your health carrier is the same carrier that you had when the patient was originally diagnosed and treated, you should have a very easy time persuading the health plan to assign a case manager.  You may even get the same nurse.  If not, you might want to put together a written request for the current health plan, to document the original treatment plan. Just remember to stay as calm and unemotional as possible.  They'll know how urgent this is and work with you to find the best solution.  Many health plans automatically assign a case manager to complex cases.  </b>

I'd suggest calling the health plan and finding out how to contact case management directly to determine whether they have an automatic assignment protocol, or if you need to request the case manager.

Check with Customer Service and or case management to find out how to select or help in the selection of an oncologist. Find out if you are absolutely restricted to a limited network of physicians, or if you can seek services from a wider network of physicians. You may want to do a search to find out if there are resources available to help you shop for a specialist; look for personal recommendations, and don't be afraid to schedule an interview process.

If you're contemplating alternative treatments, ask whether any alternative/eastern medicine services are covered, or if there are any discount relationships with alternative/eastern medicine practitioners available. Blue Cross and Blue Shield of Minnesota has recently established an alternative medicine network of providers with whom the plan has negotiated discounts for services. Minnesota subscribers can access alternative services directly, without a referral, for the negotiated discount amount. California is so far ahead of the Midwest on this stuff, its possible that your health plan has a similar arrangement.

<b>If you hit a total roadblock, find out what the patient rights are in your state. Every health plan has a patient/member bill of rights, and many of them are based on state mandates. Find out if there are any advocacy groups in your vicinity, and check with the Commissioner of Insurance for the state, to find out if there are any mandated appeal provisions at the state level that you could pursue.</b>
I hope that this has given you a little help.

[NOTE: in dealing with ANYONE, get deadlines for responses, do not allow "we'll call you" without a specific deadline.  If that deadline is reached and surpassed, you call back and keep calling until the situation is resolved. doctordee]
