<b>Petitioning for Coverage of Disputed Treatments
  
Dealing with Medicare</b>
 
From: Margaret
Subject: Emergency Medicare Question
I have an emergency and only have a few hours to figure it out - Georgia was on Gemzar for two months and then on Navelbine for the past three months. We received five letters yesterday from Medicare stating that they had reviewed her case and none of these chemo treatments were going to be paid for! They said she did not fit the criteria for these chemotherapies. The Navelbine has brought stability to tumors that were otherwise doubling in size in less than two months. 
I've called Medicare but they said that they had reviewed the case twice and the same decision was made. Georgia's due to have her next treatment today - in six hours. Any suggestions before we get to the doctor's office and face this dilemma?! Please write to me directly at so I can receive any advice you have to offer immediately.
Thanks!!!!! 
 

From: Margaret
Subject: Medicare dilemma
Great news! 
<b>I spent several hours on the phone with Medicare this morning, working my way up the ladder of authority. Finally I reached someone who was sympathetic to the situation and did more than say they were sorry, there was nothing more that could be done. I explained that lms was an extremely rare cancer and there was no "gold standard" for it. I explained that the chemos they were denying were actually working and saving Georgia's life. 
She asked the name of the cancer and looked it up - nothing. Then she asked where the tumors were located and I told her. She did some extensive research and found out that by coding the bills in a slightly different way, they would be paid! She even went so far as to call the gal at the billing office and explain to her how this needed to be done! </b>

When we arrived at the oncologist for Georgia's chemo treatment he told us that he would have gone all the way to court to fight this for her and would never have just cut off her treatment. But he was extremely thankful that we had pursued the matter and found the simpler course of action. So Georgia got her chemo, the doctor was happy and the day was good. Thanks to everyone who responded with wonderful advice and experience. You're all the greatest!!!! Margaret
 
<b>What arguments did you use?</b>
 
<b>I explained repeatedly as I worked my way up the ladder of authority that lms was an extremely rare disease with no "Gold Standard". The few chemos (Adriamycin and ifosfamide) they had listed as approved for this disease were far more harmful and less of a chance of working than what Georgia was already taking. I also had the advantage that Georgia had just had a CT scan showing that the Navelbine was indeed providing stability to tumors that were otherwise growing rapidly. The manager I finally spoke to last asked where the tumors were now. I told her that they were in the retroperitoneal area and left lung. She did some extensive research and said that if we billed it as a "peritoneal neoplasm" instead of lms, it would get paid!</b> She even called the doctor's office and explained to the billing office how to do this. I'm sure it helped a bit that my background is in health insurance, and I'm sure it helped even more that I simply would not take no for an answer. When we got to the doctor's office that day, both he and the billing gal thanked me profusely. He said that he was going to appeal the decision and would have gone to court to get this paid if need be. He would not have stopped the treatments, and for that I was thankful. But he was very appreciative that he would not need to spend hours of his time battling this obstacle. In the end: the bills get paid, Georgia gets her treatment, and ol' Margaret ends up feeling pretty good about herself - not bad all in all:)


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Last update December 2001  
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