Extended treatment § insurance coverage

[Fubarcat]

I just received notification from Blue Cross/Blue Shield that they weren't paying my April meds because they needed "additional support from my physician to justify extended treatment".  Well, as usual, the insurance company messed up.  I am not on extended treatment(yet) as I am only 21/48 as of today.  I called BC/BS and they agreed they screwed up and would submit the bill for payment.  They indicated I was approved for meds through December 2004.  

BUT - that got me thinking.  How do you get authorization for extended treatment if you need it beyond the generally accepted 24 or 48 weeks?  REV:  I know you are on extended.  How did you get your insurance company to cover it?  I wonder if they will do it if your doctor writes a note to indicate it is necessary.  That must be a huge fight between patient/doctor/insurance company.  God knows, BC/BS isn't going to pay anything without putting up a fight about it.  

Anyway, I guess I'm just obsessing since I am not on extended treatment at this point and I don't need to worry about it for another 6 months, but it was just a question that popped into my head.

[mikesimon]

You know I've wondered that myself. I think you have to first appreciate that insurance is largely a bookmaking scheme. The insurance companies analyze the degree of risk and magnitude of harm(cost to them). I have never had any trouble with insurance and I think that is because 1) they already are in for a transplant to the tune of > $400,000 and 2) the insurance doctors are probably not about to second guess transplant surgeons and hepatologists regardless of guidelines or parameters of treatment. So for the ordinary patient I think the treating physician must provide some reasonable evidence that eradication could preclude far more expense to the insurance company e.g... transplantation, regularly scheduled biopsies, ct scans etc. and that extending treatment is a reasonable approach to viral eradication. This shouldn't be too difficult in light of the new studies that are coming out. I think that if your doctor is not armed with this information it is incumbent on you to provide it. Good luck. Mike

[nolee]

I work for a company that is self insured but administered by a 3rd party. There are case mngt. teams that hammer these things out with Drs., providers etc.... With my case, the admin. declined to pay for the therapy at all. Then it was 60-40, then 90-10%. Our HR person took it directly to the Pres. of our Co. and he over-rode everything the admin. people suggested and I just pay $40 co-pay. They REALLY went to bat for me. I must be
S P E C I A L!! So my point is everything is subject to change and confusion when dealing with insurance companies but for the most part there is always a fairly  good outcome. They can't deny coverage for a sick person once they have paid anything. Good luck and let's hope you don't have to extend....Neal

[Fubarcat]

Thanks for your comments.  Scott:  Good idea about starting to get the paperwork in line before extended treatment is necessary.  I have an appt on 6/25/04 for my 24 week PCR.  Since I was undetectable at 12 weeks, I think I'll wait to see what 24 weeks has to say, and then I will know whether or not I may need extended after that.  That sounds like a good plan, right?  I mean my doc probably won't want to extend if I am still undetectable at 24 weeks, right.  Is there a reason to extend if you are undetectable at 12, 24 and (hopefully) 48 weeks?  I'm 1b.  Thanks!

[TnHepGuy_]

Factors that go into the SVR/extended tx decision making process:

(from the <a href="http://www.natap.org/2004/EASL/easl_17.htm">SVR Calculator</a> paper):

"<i>Important baseline factors include HCV genotype, HCV RNA level, age, BMI, ALT quotient, presence or absence of cirrhosis, and assumptions about adherence.</i>"


(from the <a href="http://www.natap.org/2004/EASL/easl_06.htm">TERAVIC</a> study):

"<i>The authors also said that further analysis of the data suggests that the probability of achieving a sustained viral response is inversely proportional to the time taken to achieve undetectable HCV RNA levels. This leads to the hypothesis that extending the duration of treatment in patients who fail to clear HCV RNA rapidly will increase the sustained response rates. This strategy may be particularly important in patients with 'difficult-to-treat' characteristics, including those infected with genotype 1, high baseline viral load, previous nonresponders, and HIV-infected.</i>"


TnHepGuy

(URL's for the above papers):

http://www.natap.org/2004/EASL/easl_17.htm

http://www.natap.org/2004/EASL/easl_06.htm

[Honey15637]

Ok...Didn't really want to hear that but....I guess I knew deep down that this may be coming up for me and others to decide on.  What do you feel would be long enough to go....52 weeks? Or a year and half?

[cuteus]

loved that model to predict outcome.  TY so much. I am now calculating my svr outcome, or trying to.

[Amerabrit]

Not what I wanted to hear either, but I have been suspecting that 48 weeks might not be long enough (according to the posts and links listed here). Right now my last shot is scheduled for New year's Eve; wouldn't that be something to celebrate?
Ok, now I too, need to calculate my response rate?

[Ambush]

I am on week 54/56(?) now and the doctor's office must have handled any insurance questions about extending tx.  I never heard a word from anyone.  I usually get a letter from Blue Choice stating that my meds have been approved (like at 12 wks when they want to see vl reduction before continuing tx) or for Procrit (big bucks).  My guess is that there was no approval needed to extend or I would have gotten a letter.  Not sure.  Whoever handles the insurance in the office could tell you how it works with your coverage and if it has been a problem in the past.
I'm with you Rev, don't want to do this again.  Doctor is saying we'll go to 56 weeks.  Now that I'm getting close, I dread quitting too soon.  This is such a **** shoot........
ambush :)

[Honey15637]

LOL Yours is new years eve and I would be right ahead of you approx Christmas,,,,Darn! I know I don't want to extend but everything that rev and tnhep posted...looks like we should consider this.  And I know for a fact,,,,I do not want to ever start all over LOL

[Honey15637]

LOLOLOL We know you are hooked but do we have too extend?

[cindee]

Hey family, I for one think that had my "dumb doctor"(1st doc), extended tx. I may not have relapsed w/ only 48 wks. But at least I've found a wonderful doctor to treat me now. Being that it is a clinical trial and everything as far as meds... that's all I know of right now is FREE. That is definately a PLUS. I forgot to ask if bx will be free as well @ doctor visits too. I will ask that when I see my new doctor next time.

As for insurance.....I have Blue Cross Cobra Solutions because I am on disability. But my Cobra runs out Nov. 1st. My disability claims rep. has contacted S.S.Disability, about 2 months ago, and I haven't heard a word from them. I talked w/ my disability rep last wk and told him they HAD NOT contacted me yet. So what will I do when my Cobra runs out? I still NEED health ins. My hubby can maybe put me on his insurance @ work, but being that we worked for the same co.....I really don't think it would matter, because any insurance co. would check my health background. Are they going to turn me down...saying "pre-existing" condition????? But maybe say they won't cover any hep c related problems????? Would that mean any time I have to go to any of my doctors..they would say "pre-existing"??? Then what would be the use for him to cover me?

If anybody has any answers to my questions I would greatly appreciate your in-put. Maybe I should contact S.S. myself? This has had me greatly stressed. So TY for any answers.

I hope you ALL have a wonderful and SAFE Memorial Day week-end, and for those treating I wish you little or NO sx for the days to come. I love you all, Cindee

Scott, Please tell me how you keep such "wonderful spirits" while you are going thru so many weeks???? I never hear you complain about not feeling well...are you one of the lucky ones to not be having many sx????? You amaze me! And I mean that from the bottom of my heart!!!!! I complained ALOT while I was on tx. And I can NEVER remember you ever having complained even once!!! PLease tell me your "secrets" before I start another journey soon!!!  Hope you have a fun filled week-end!!! Much Love @ Many Prayers to YOU @ Everyone, Cindee

[cindee]

Chevy, TY for your in-put...I to am one of Scott's top ten admirers.

And rev...since you recounted that story of the "flying squirril"....I think you "pinged!!!!! LOL" my brain!!!! I know I read stories but I forget many of them. It's like the time the sherriff told me to move, when I had let my g.daughter out @ the only entrance to a store. I honestly thought it was okay to stop...but not Park..in a fire zone...I still had my car running. He said a few words and I explained to him I was too sick to go in and had let my g.daughter out.( she just wanted some ice-cream!)  He still insisted that I move, so I did...I turned directly infront of him (it took about 3 turns...LOL) and stopped. I know he could tell by the "demon look" I gave him, that I was not going to let ANYBODY cause anything to happen to my g.daughter. With that he just went around me...shaking his head all the while!!!!! So thanks for "pinging" my brain. I guess you do sometimes complain, but always in a pleasing or "funny" way! Love to you both,  Cindee  p.s. Scott I will call Tuesday and begin my "own fight" w/ S.S. Disability......Like you said I am a FIGHTER....I will not give up!!!! I will not let the insurance **** put me in an early grave!!!!!! TY again for your in-put, I always count on you for knowledge and advise!!!! Have a great week-end. Much Love, Cindee

[cuteus]

there are at least 20 top ten Scott's admirers,  maybe more.  how can we all be in the top ten?