Insurance Company Agreed With Me!

Make way for a Victory Lap! Yup, that would be for me! It’s Exclamation Point Day!

Here’s the latest happening on the fight for Freedom from Debt.

The insurance company (IC) has, after careful review, agreed with me.  They’ve decided to reprocess my claim.

Let’s review the case a little.  Twice the IC denied my request for payment of the laboratory services meant to determine the new mutation of my lung cancer tumor. The reason for the first denial was that Dr Brevity did not furnish the requested paperwork. After Dr Brevity furnished the paperwork, came the second denial with a new reason: My Primary Care Physician from the IC network was not the requestor of the services.

The IC changed the decision because the diagnosis is lung cancer for which molecular pathology testing (Guardant) was requested.  The Medicare Program Integrity Manual Chapter 13, Section 13.5.1 indicates that in order to be covered under Medicare, a service shall be reasonable and necessary including service being furnished in a setting appropriate to the patient’s medical needs and condition and one that meets but does not exceed the patient’s medical needs.

Based on this decision, my claim has been reprocessed.  According to Medicare regulations, this claim must be reprocessed within 60 calendar days of the date they received my appeal.

In view of the latest event, I am tempted to crow that I’m an indomitable senior babe who refuses to bend to anyone who gets in my way.  But I can’t do that.  Tons of help came my way.  Guardant represented me in my last appeal.  Seasoned Medicare case appellants, they definitely know they’d get paid when I get paid.  In addition, the IC wrote me the letter of reconsideration. All I did was read the letter and expressed everything in first person.   Less than 30% of the language in the preceding paragraphs is mine.  In other words, I’m no authority here;  just an honest crafty blogger who tries to get away with sounding impressive.  That’s all.

Now success-in-progress has gotten me intoxicated.  I’m staggering on, figuring out how to totally eliminate any co-pay.  Push a little farther while the momentum exists!

Isn’t that an awesome turn of events?

 

 

Insurance Company Denies Payment

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Not a Pretty Picture!

 

My life is filled with conflict.  Fortunately, I dig conflict.  Being a self-proclaimed Drama Queen, I thrive on conflict.  Conflict becomes me.  Okay, you get the drift.

When it became almost clear that rociletinib, the CO-1686 trial drug aka poksceva, had started to differ with me as to its purpose in my well-being, my awesome Onc, Dr Brevity, decided to requisition the services of Guardant.  Guardant is the noted high-tech company that analyzes human blood to determine the types of mutated cells that are coursing through the veins of a cancer patient.  Dr Brevity said he wanted to know what happened to the cancer cell that was once identified as T795, a mutation developed out of my EGFR in exon 19 deletion to resist Tarceva.  Cancer cells do learn to outsmart cancer drugs!

I asked for the results of Guardant’s lab analysis as soon as it became available.  Like the Good Doctor, I wanted to know what new nasties were parading in my system.

I read the report with great interest.  The only problem was, I did not understand a thing about analysis of DNA, genes, and molecular pathology.  Well, what do I know about molecular pathology? I’m a civil engineer; I’m into sewers.  But I got the hang of what the report was saying: Those analysts did not know what to make of the results either because there was not enough material in my blood, consequently, they did not know what treatment to recommend.  So, now, a whole slew of us including Dr Brevity, the analysts, the CO-1686 trial sponsor, its employees and associates, and me, know more than what we did before Guardant came into my existence.  Zip, zero, nada.  And my insurance company put me and only me on notice that they will not pay for the lab’s analytical services.  In other words, you, Ms Senior String-Bikini Babe, shall pay.  The scenario reeks with conflict of interest!  The insurance company’s interest in my funds conflicts with my interest in not paying for anything whenever possible.

Well, I happen to be a veteran of conflicts.  In public events, when the emcee asks veterans in the audience to stand up and be recognized for their patriotic service to the country, I attempt to join those who rise, but a companion always pulls me down and puts me in my place.

I read the letter of the insurance company word for word and found I have 60 days to file an appeal.  I can name a relative, friend, attorney, doctor, or someone else to act as my representative.  The most logical representative is Dr Brevity because he was the reason for the payment denial, which, by the way, was given:  Medical records requested were not received.  In order to determine financial liability or medical necessity medical records are required to assist in a clinical determination. As these records have not been received, this claim is not payable by the insurance company.

It was my turn to put somebody else on notice.  And I did.  Voila!

(to be continued) 

I’d be glad to hear your experience if you have any on insurance payment denial of Guardant’s services.