Dr. Esserman ordered the Oncotype DX Test for me over 1 month ago (see post “What is Oncotype DX?”)
Today I received Blue Shield’s denial letter stating:
“A physician advisor has reviewed the information provided and determined that the requested service would not be covered as medically necessary under the terms of this health plan per the BSC Medical Policy: “Gene Expression Profiling for Managing Breast Cancer Treatment.” Specifically, A Blue Shield Medical Director has reviewed the submitted medical documentation and has determined the service is not medically necessary as established in Blue Shield of CA Medical Policy. The clinical rationale used in making this decision is”:
– Documentation does not demonstrate that the patient was recently diagnosed (within six months)
– Documentation does not demonstrate that the patient will be treated with adjuvant hormonal treatment.
Now I know why BS stands for Blue Shield!
I called Blue Shield and reported a grievance. The process, they say, can take 30 days.
Here we go….
I feel your pain. I’m still waiting on reimbursement from BCBS for all my out of pocket (covered) adjuvant therapy dating back to August of 2011. The process began with denials, then protest, then resubmissions, then incorrect processing, another protest, resubmission, partial denial, protest, resubmission, incorrect processing (they paid .23 cents!), resubmission and finally being told payment was processed, which I have a check number on but have never received the check. Because of the confusion I asked for something in writing from BCBS confirming the coverage for 2012. I received confirmation that the nutritionist would be covered 100%, that she should submit the claim directly and they would send payment to her. Soooooo….first visit she submitted was about 5 weeks ago. Last night I received notice of a processed claim. Opened the claim report and, yes, DENIED. The reason given-these services are not covered under your plan. I’m thinking of getting an attorney.
There is something DEEPLY wrong with our health care system. The drug companies, the mammography/radiation pushers, the insurance companies, the BIG cancer nonprofits and the doctors/hospitals — they are all in cahoots! They are all contributing to our disease management system and WE must all do what we can to stop the breast cancer insanity! Sharing our stories is the beginning! Thanks Kay!!!
I am just now getting the opportunity to check this out – I think it is great. I too have spent innumerable hours dealing with insurance companies and had experiences similar to Kay’s above. I am thinking we should band together and do a class action suit against BS. I agree that there is something deeply wrong with our health care system, BUT it is a reflection of our society at large. There is also something DEEPLY wrong with our education system and other institutions. Thanks for putting this together as a vehicle for our voices to be heard.
Enjoyed talking with you two weeks ago. Glad we will be able to keep in touch. I am peer counselling a few others do you mind if I pass on the site address?
Take good care,
Glad to hear from you! Thanks so much for your feedback!! We must continue to share our stories — it is the only way for change to happen! Please share my site far and wide!!! And also, I’d love if you posted your story/perspective as a comment under “stories.” I have been scolded on breastcancer.org – I was told not to promote my site! I have also gotten some comments there that they have concerns about me leading the way for other women with poor margins. Yes, we should ban together in every which way!!! Maybe we will make a documentary!
Stay in touch, stay in the light and stay healthy! ~ Donna