Gated Breathing Radiation Coverage

abender · January 2011

Hi. I went thru my chemo (Farber clinical trial) for my her2 positive breast cancer on the left breast. For the radiation, the hospital strongly recommended I use their new Gated Breathing radiation machine which is much more precise and would help spare my heart and lungs from the radiation. Sounded great to me! It called for 19 treatments. After the 13th I got a denial of coverage notice from Blue Cross Blue Shield of North Carolina. I appealed the decision all the way to the state board and it was still denied! The hospital knew my policy and should have informed me about the lack of coverage-- called it experimental. Has anyone out there had the Gated Breathing radiation done AND had it covered by insurance?

Thank-you

Alice

Margie10 · January 2011

Hi - I also received a denial from Anthem Blue Cross for gated radiation (continuing to appeal). Did they deny your entire bill or just a portion of it? Radiation is pretty standard...I don't understand why they deny the entire cost.

abender · February 2011

I am sorry to hear that you too have been denied. I hope your outcome is better than mine. The entire bill was denied by insurance. Radiation was standard of care but they claimed that the gated radiation was not necessary and experimental. Standard radiation would have been good enough I guess. The hospital did reduse the cost for us because the doctor still felt it was the best treatment for me.

Letlet · February 2011

Wow, I am so sorry that happened. It doesn't make any sense, if you ended up with heart and lung damage, wouldn't the insurance company pay more in the long run??

HollyinMich · March 2011

Letlet, that would require that insurance bureaucrats have common sense!! Look how long it took the insurance industry to cover contraception. Lol, the cost of birth control pills, or a one time procedure has always been more cost effective than prenatal care, the birth itself and the addition of new person to the plan that requires frequent check ups, vaccinations, etc. They're not too bright!

Alice, I'm sorry to hear that you are having to fight yet another battle whilst fighting the most important battle of your life!! I wish you luck in getting it covered!

edwards750 · March 2011

This is an interesting discussion for me. I am going to have to have radiation which should begin sometime in May. I also have Blue Cross - of Tennessee. We have a large deductible so the first 5k is pretty much on us but after that...we are fortunate that we are part of the Blue Cross PPO so most of the procedures are discounted. As if we don't have enough to worry about. My husband and I also have a flex plan, although it is won't pay all the medical bills, has helped. I am going to be on a permanent payment plan but I really don't care. I think the doctors should have informed you ahead of time although they always have this disclaimer that says it is our responsibility to make sure our procedures are covered. I get treated only by in-network doctors....still insurance does need to get a grip...

Margie10 · March 2011

I did my homework before radiation treatment began; verifying radiation was covered in my insurance plan document (I have Blue Cross PPO network); selecting a hospital designated as "center of excellence" by Blue Cross. No where in the plan document did it state that gated radiation was not covered or experimental. Blue Cross is denying the entire bill based on a vague clause in the plan document that it will not cover "experimental" procedures. My doctor and hospital considers gated radiation "standard of care" for breast cancer and not experimental. Gated radiation is covered by most other insurance companies, but not Blue Cross. I can't tell you how frustrated I am that they continue to deny payment and refuse to consider doctor's opinion from their designated "center of excellence". For your reference, the bill will far exceed your $5k deductible (more like $100k).

edwards750 · April 2011

Just found out once you pay out of pocket - $5k worth in our case - Blue Cross/BS of Tenn pays 100%. I hope they pay for radiation; havent heard otherwise and I will be starting my treatment April 28. I wish I could have that procedure it would so much easier to tolerate than 31 treatments. I think I am going to find out tomorrow if they will pay for that although the rad onc hasnt suggested it. I will check with him too.

Margie10 · April 2011

Although radiation was a covered expense in my health plan document (I verifed before treatment), Anthem Blue Cross denied payment since I received gated radiation (under a general clause in the plan document to exclude any services they deem "experimental" or "not medically necessary"). Although my doctors from a Blue Cross designated center of excellence deemed gated radation "standard of care" and "medically necessary" for me, Blue Cross will not agree. I highly recommend that you understand the exact type of radiation that you will be receiving and verify approval with Blue Cross before treatment. They have consistently denied reimbursement for gated radiation (which far exceeds your $5k out of pocket limit).

Taderbug · July 2011

Wow, I realize it's several months later, but I'm going through something similiar with Anthem. I've been denied now on two appeals. I was wondering did they ever approve. Can't figure out how an insurance company can deny a treatment that causes less tissue damage?

Margie10 · August 2011

Unfortunately, Anthem has denied all my appeals. It is all $ with them...gated radiation is more costly. In the long run, gated radiation would save costs by reducing future complications; however, they don't know how to quantify that (the brightest financial minds do not work for insurance companies). I guess they are managing for short-term profitability.

peggy_j · August 2011

Wow, sorry to hear this. After seeing the bills for my regular radiation, I know that treatment isn't cheap. This might be a long-shot but I wonder if any of the states' consumer health-insurance boards can help?The state of CA actually sued Anthem Blue Cross a couple years ago for rescinding policies. (when Jerry Brown was attny. general. He's now governor, so hopefully the administration is still consumer-friendly). Seems like insurance should pay the price of regular radiation at least. Another thought: I wonder if any lawyers want to take up a class-action lawsuit on this. Is there anyone like the ACLU for people who've been ripped off by the insurance companies?

Gated Breathing Radiation Coverage

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