#metsmonday – Insurance crapoola

This article has been making rounds on FB and could not have come at a more fitting time as I am finding out I need to participate in an external review to get the chemo I received from last fall covered.

I don’t know how many peer-to-peer reviews my oncologist, Dr S, has had to go through already, arguing my case up till this point. I received a approved therapy for Her2 metastatic cancer. The issue I gather is that I did things out of order.

My initial mets diagnosis was metastasis to the brain. I had two large tumors surgically removed, took part in a drug trial and then had radiation. At that point, no cancer, via CT scan had been detected in my body. I was prescribed an oral therapy that would cross the tricky blood-brain-barrier and help kill any residual cancer there.

Right before I started taking it, a scan showed small lesions on my liver. We decided to wait and see if they grew. Two scans later, they had not changed much so I finally got a liver MRI. The liver MRI showed that the lesions were consistent with liver metastasis. Since they were there before I had begun my new line of therapy we decided to continue that therapy but add in a chemo drug. This added up to a common therapy used in Her2 mets but one generally used as a third line therapy, not a first. But since this drug combo was able to treat both my body and brain, it made sense as a first line of therapy FOR ME.

A few months later, when a scan showed liver progression, we decided to switch to first line therapy – which is a taxane chemo with two targeted therapies. This is the therapy, insurance is trying to deny. From my understanding, the grasping at straws argument they are trying to make is that because I did things out of order, the therapy should be considered experimental and not be covered – even though a Taxane plus the two targeted therapies are a recommended and proven therapy in the established guidelines. But I did things out of order because my cancer is different than other people’s cancers. Mine showed up, or at least gave me symptoms, in the brain first. That isn’t real common but it is getting more common among the Her2 subtype. But because the insurance “doctors” are not specialists, they don’t get these nuances. They don’t get why it was the right decision for me, to do treatment out of order. That I needed to attack the lesions in my brain, then switch gears and attack the lesions in my body. That’s also why they didn’t understand that the patient in the article above needed a PET scan over a CT. We are just numbers on paper, not actual people with unique disease profiles. They don’t want to come across that way, so they throw in chummy terms like “peer to peer.”

Sorry but I’m not getting warm fuzzies here. I’ll save those for Dr S and the great medical professionals who put in long days at work, sacrifice time with family and loved ones and have to fight this BS on top of everything.

As much as I’d love to rail against the US healthcare system, the treating every patient the same and the ticking off of abitriary guidelines (that conflict with the actual guidelines) is an issue in many other countries. That’s why it took so long for the NHS to approve Kadcyla. That’s why many Canadians cannot access Ibrance. That’s why Herceptin continues to be cost-prohibitive for South Africans.

Our lives are more valuable than saving a buck. Patients deserve more and our talented doctors deserve more than to be patronized.

#metsmonday – Insurance crapoola

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