Blue Shield of California To Salon's Cary Tennis: Drop Dead
Salon's Cary Tennis is one of my very favorite writers. He's on hiatus from his "Since You Asked" advice column there, where he's written quite movingly of his journey toward sobriety. Instead, he's been blogging about his cancer fight.
Now he faces an even bigger battle: one with Blue Shield, and he needs our help:
I've been recovering from cancer surgery and waiting for the insurance company to approve the next course of treatment, which is eight weeks of proton beam radiation therapy at Loma Linda Hospital in Southern California.This treatment is what my surgeon, Dr. Christopher Ames of UCSF, calls the standard of care for sacral chordoma.
Today I learned that the insurance company has denied the request for this treatment. Dr. Ames is a noted expert on spinal tumors. That's Ames in the ABC7 News video below -- taking four vertebrae out of a woman's neck and ... well, just watch the video. This is the guy who operated on me:
Dr. Ames says that 8 weeks of proton beam radiation therapy at Loma Linda Hospital is the standard of care and I believe him. So I called Blue Shield. They told me to fill out this grievance form.I put the grievance form PDF on my Web site, where you can download one, too. Maybe if a few hundred, or a few thousand, of these forms were filled out and mailed to Member Services Grievances, Blue Shield of California, P.O. Box 272540, Chico, CA 95927-2540, well ... maybe it would get some attention. Or maybe if you called (800) 424-6521, which is the number that people with grievances are supposed to call, maybe that would get some attention. On the back of the form are instructions about how to contact the California Department of Managed Health Care. Their phone number is 888-HMO-2219.
Sacral chordoma is a very rare cancer, and proton beam radiation therapy is not a well-known course of treatment. Plus it is expensive. So naturally an insurance company is going to carefully review a request for such treatment.
But Blue Shield wouldn't deny me needed care, would they?I don't want special treatment. I want the same treatment anyone else would get. I just want treatment.
and the Health Care IRS enforcers will still take your money.
You're in full-on panic mode today.
First, no one forced Mr. Tennis to get coverage, right? But he's got coverage? And he's appealing the decision? If he had no coverage, his cancer may have been found so late that no treatment would help him, or he simply wouldn't be able to afford the treatment, let alone appeal for the treatment.
Second, please show me a health system anywhere in the world that unquestioningly pays for every prescribed procedure or drug.
Don't try to confuse the issue with half-truths and gorilla dust.
with no co-pay or lifetime limit or deductable
Really?
Or does the Canadian health care system look for work-arounds when possible? There is some rationing of care there, iirc.
Don't try to confuse the issue with half-truths and gorilla dust.
Give facts...
You can not because Canada's treatment to it's citizens in far greater and much cheaper than that of this private corporate controlled health care in US...
http://www.ourfuture.org/blog-entry/mythbusti...
We know d... well that we lose at least 30 percent off the top when they take this money for the profits , salary and bonuses.
There is no getting around this..
By the way where in the h... is all these billions and must likely trillion of dollars the health & Drug companies are spending by their lobbyist and to elected officials to get their way..
Is that from their profit h... no that why the when up as much as 39 percent on the policies..
http://www.youtube.com/watch?v=io7x8p2GwZI
http://fdlaction.firedoglake.com/2010/03/17/p...
None
...doesn't address my question at all. Hop down the thread a bit and you'll see what I'm talking about.
Don't try to confuse the issue with half-truths and gorilla dust.
If you're not covered?
It's like paying for life insurance, then when you're hit by a bus, the insurance company has a panel decide whether your death was spectacular enough or your family was deserving enough. It's a lie and it's theft.
If the treatment is available, they should pay for it. If they can't pay for it, the system is broke and needs to be fixed. It's one thing to pay for plastic surgery and botox, but this is a guy's life and there's treatment available.
I was on Blue Cross/Blue Shield in the States and they denied coverage they were supposed to pay for, because of doctors and labs filling out paperwork wrong. And I was healthy!
I won't move back to the States with the current healthcare system. My life is more important than being able to call myself an American.
recission is still allowed (though reviewable) under the new proposal.
Yes, that's exactly what it is. That's why I can't understand why health insurance for profit was ever legal to begin with. It should be a completely NON-PROFIT industry. Otherwise it's inevitable that the problems we have now would come to pass. Put profit in the mix, and it'll end up being about profit and ONLY profit.
Theft and murder. That's what it boils down to.
There's always free cheddar in the mousetrap, baby. - Tom Waits
My point is that even in the best examples of health care systems we've ever seen in the world, there is some rationing. The further a treatment is from being considered routine, and the greater the costs, the greater the chance that the provider- be it the National Health in England, the Canadian system, the French or even American private "Cadillac" plans- will steer its patients towards more conventional and cheaper procedures until such a time that it's apparent that those conventional and cheaper methods aren't effective. Just because there are no profits involved in a nationalized health care scheme doesn't mean that there aren't costs involved.
Don't try to confuse the issue with half-truths and gorilla dust.
What you are talking about does NOT apply here. As the article clearly states, there ARE no "conventional and cheaper methods". What his doctor is recommending is as close to conventional as it comes. In other countries, what they cover would include Cary's proton beam therapy. Motorized wheelchairs with tongue controls aren't cheap either, but they get paid for.
...between Cary and his doctor. Fox told me that a government plan would put the government between me and my doctor, implying that such a thing is bad. Instead it appears that a bloodsucking profit-grabbing insurance company is standing between Cary and his doctor. How come Fox didn't tell us that's what's happening with for-profit insurance? Oh, that's right, I forgot...
Rich people pay Fox people to convince middle class people to blame poor people. Telling the truth isn't part of their job description.
HCR without a public option is like spray-paint on rust. Pretty, useless.
My sister lives there, and they pay for whatever you need.
See, that's what "national health care" means. EVERYTHING YOU NEED. We're so many light-years away from that, most of us don't even know what it entails. That's why the scumbaggers can go around telling such gross lies, because so few people in America even understand the concept of universal health care.
There's always free cheddar in the mousetrap, baby. - Tom Waits
Of course it only going to cost $525,000 whats a few bucks amongst friends? We figure out how to get a buck a piece from half a million folks and it won't cost ya a dime. Doc Holiday
Especially when insurance companies are paying bonuses and salaries two or three orders of magnitude greater than what it would cost to treat him. It would be a lot simpler just to put the upper bracket taxes to what they were under Reagan and the money would be there.
Extortion
. . You can write and complain, call and yap, wave your finger at them in shame, or imagine a laid-off engineer -- a genial, capable fellow, once valued by his former employer -- tinkering in his Ohio basement with a device designed to blow up the headquarters of the health insurance company that has just denied his wife treatment for cancer of some organ or other.
It's outrageous.
Good luck to Cary Tennis.
Sarah & Glenn told me that death panels won't go into effect until after our Socialist Liberal Fascist gummit takes over health care and not before.
Are we going to treat this jerk he has no insurance, no assets, a half ass job, no jack squat!
They already do this.
The good news is that he doesn't have government run health care which would include death panels.
But fuck the GOP, fuck the Teabaggers and fuck the insurance companies. These people want us DEAD.
Will gladly fill out the form and call but don't we need more information or is the name enough?
You'll need specifics on his case, which is why it won't work.
There's always free cheddar in the mousetrap, baby. - Tom Waits
A "mild dictatorship" implemented by a "magical governance".
of course they would... such action is standard operating procedure with for-PROFIT insurance companies...
accept the premiums...
fuck the policyholders...
after all, if they paid OUT for health care, where would all the money be when bonus-time came rolling around?
Just pay for it out of pocket. Don't wait on the insurance co. Damn I hate these republiturds.
I understand the teaparty people being mad a government. The government has done plenty to be mad at them for. This insurance bill is just one more reason. What I don't get is that these fools don't see that it was the republicans that screwed everything up! If the republicans had been working to make things better for everyone, not just the rich, we would not be where we are right now. You can't fix stupid and the GOP is about as stupid as anything we have ever seen. I am so ashamed of 40 million Americans that I cannot express the depth of the shame I feel for those who cannot feel the shame for themselves.
These people do not have the morals or the intelligence to make sound rational decisions and should not be allowed to participate in government. Every thing they do is wrong!
republicanism/conservatism is a mental illness. They have killed the economy and god only know how many people. Please god damn the GOP!
What are they doing? Besides encouraging everyone to watch television and consume Obama Soma.
lower, teachers aren't compensated enough and college is continually being priced out of reach, ensuring more and more uneducated and more "stupid" people ensuring the republican party an ever growing base.
Health Insurance Giant Gives $110.9 Million Compensation Package To Ex-CEO.
Get it now?
I know I've been slamming the bill for what it could have been, but I've also posted if it helps save lives then go ahead and pass it. One of my sisters who live in MA has no insurance and a very advanced form of cancer, she's receiving treatment and progressing quite nicely. If she didn't live in MA there's a good chance she wouldn't be here.
On the other hand, she went to the doctors for regular checkups and nothing was ever discovered (prior). I think that will still be a major problem with for profit insurers, the offered plans will run from "basic" to somewhat better to best. If you can only afford basic would those tests even be run?
If you believe only the rich deserve to live longer and suffer less, then the U.S. system is the one for you. It's a selfish system that ensures the suffering of the many for the financial benefit of the few. And there is no reason in a country with the extreme wealth of the U.S., everyone shouldn't be cared for. It's in the country's interest to take a preventative approach and catch stuff early. Whereas it's in private insurance companies' interests to ignore and deny.
I would like to pay fewer taxes. I am not rich as a matter of fact I don't know how much longer I can pay all the things that I have to pay. I haven't had a job in more then a month and the last one I had didn't make any money. My general liability insurance company wants to triple my rate. There is no way I can do that. Things are a real mess and I am worried about what we will do. We have not had health insurance for more then a year.
I get so down sometimes, but I guess I will see what tomorrow brings.
The big corps and the uber rich are giving the rest of us the shaft.
We may need to get our pitch forks and clean washington out.
republicanism/conservatism is a mental illness.
The problem is who's paying them and where they're going.
The country could have universal healthcare tomorrow if we simply did two things:
1) taxed progressively, as we used to, and EVERY other advanced country does. Under Eisenhower, the wealthiest were taxed at 90%!!! Now, thanks to tax breaks, they usually pay a smaller percentage than people making $40k.
2) cut back military spending to a realistic, rational and intelligent amount, that would still make the U.S. the most effective military force in the world. You can't have the money you need for education, vital infrastructure and healthcare while spending 50 cents on every dollar on military.
if you didn't have to pay for health insurance AT ALL?
Think about it. Wouldn't, say, 10% more on your tax bill be worth the thousands you wouldn't have to pay out to the vampires at your HMO? I'd be happy to pay a bit more to the feds if it meant I'd NEVER AGAIN have to worry about whether I could see a doctor when I need one.
There's always free cheddar in the mousetrap, baby. - Tom Waits
insurance and tuition. If only. Sadly, there's a good portion of americans who think the world ends at the waters edge (in response to your sister in Spain post).
...the fact that we're paying for health care already, it just comes out of our salaries (if we have employee coverage.) And we're paying twice as much as everyone else in the world. I've got insurance, but I'm ready for single payer now - because it's the right thing to do, and because it will cost me less money!
We may need you and your pitchfork....
In case you haven't noticed we have no liberal TV. Everything has been stanted more and more to the right for years. I never watch the TV news shows, not since 2003. But the news ended just before 2000.
No more of their arguement being equivalent when it is not.
If we rid ourselves of the republicans we can bring sanity back to government. What we have now is insanity.
to bring back sanity in Government. Obviously they've all gone insane.
everyone that the news is "liberal." And that Fox News is a counterpoint.
HILARIOUS!!!
When's the last time anybody did an investigative report on corporate wrongdoing? Or corporate pollution? Or corporate corruption? It's all bloody authors who come out with books and 90% of the time they show up on Democracy Now!
Meanwhile, you print a flyer that has some whacky conspiracy theory that helps prove Obama's a commie and you get your own show on Fox.
Fair and ballanced! ballanced against what a whale?
I'm terribly sorry and I wish you successful and speedy recovery.
It pains me, but I think that Blue Shield may be on appropriately sound ground in this instance.
"Sacral chordoma is a very rare cancer"
Not much to go for establishing 'standard of care.'
"..proton beam radiation therapy is not a well-known course of treatment"
So, it can't be the 'standard of care.' The standard of care is radiation treatment, not a new technology that's not well known. Standard radiation treatment is an insurable alternative.
"Blue Shield wouldn't deny me needed care, would they?"
I think they've demonstrated otherwise on a large scale.
"I don't want special treatment. I want the same treatment anyone else would get."
It's available to you as the standard of care. The latest technology is not available to you, because "it is not well known."
Good luck, and for your own good, stop panicking.
when you're not the one who's dying.
There's always free cheddar in the mousetrap, baby. - Tom Waits
If it is a rare cancer, the type of cancer is not well known, so it shouldn't be surprising that the standard of care for it is not well known either.
All cancers are different. Radiation treatment may be standard of care for some other cancers - but not for this one. I think his oncologist probably knows what standard of care is for this particular disease.
(By the way, I work in cancer research.)
is the way to go, the radiation is targeted much more precisely.
good thing cary lives in california, because there are only half a dozen of these machines in the country. i hope he gets approved, this is a tough one.
healthcare rationing death panels.
me-oww!
If cancer treatment isn't standard treatment, I'm not covered under my plan. I have to buy, at a dollar a month, coverage for experimental cancer treatments.
---
For indications approved by: FDA, NIH/NHLBI, NCI, Phase I, Phase II, or Phase III Clinical Trials
Emerging treatments or therapies for cancer and other severe, life-threatening diseases:
• Conducted pursuant to an FDA, NIH, NCI, or Cancer- cooperative group approved Phase I, II or Phase III Clinical Trial. In the event a covered person is not formally a participant in the approved Clinical Trial, such treatment or therapy must be administered under the direction of a physician, follow the protocols and procedures utilized in the trial and be delivered at a facility that has been designated as a participant under the approved FDA, NIH, NCI, or Cancer- cooperative group for Phase I, II or Phase III Clinical Trial.
OR
• Where the illness is encountered so infrequently that no formal trials exist, if the proposed treatment is considered promising care by knowledgeable experts in the field and is supported by evidence of efficacy in the peer reviewed literature, such treatment will be allowed when performed within a facility that actively participates in approved FDA, NIH, NCI, or Cancer- cooperative group Phase I, II
or Phase III Clinical Trials.
Proton beam therapy for head and neck cancers
Only place where I found the word proton in the SPD
I went to the Google and entered:
"proton beam" chordoma
First thing that comes up is clinicaltrials.gov.
Unless this is considered "generally accepted", he's going to have a problem getting this covered.
is futile. You need specific information about a person's case in order to file a grievance. Look at the form. Anyone trying to file will need his case number and several other things, and they'd need it to phone in as well. Otherwise, they'll just be ignored.
I mean, PR is a great tool to shine a spotlight on this kind of thing, but going through the grievance process isn't the way to go about it. What people should do is repost and link, get it all over the internet. Through Twitter too, if you do that.
There's always free cheddar in the mousetrap, baby. - Tom Waits
Your insurance company is playing doctor. Perhaps someone should consider if they are (a) licensed to practice medicine and (b) good enough to second guess your physician. If both of these turn out to be true, they surely they can withstand the end of a malpractice lawsuit.
Meanwhile, where is our government to protect us when our own insurers become the enemy?
Pffft. He should just go to the ER.
/s
http://www.proton-therapy.org/news.htm
Which has this article:
http://www.proton-therapy.org/documents/Bulle...
Which says: "Slater points out that Medicare, which covers proton therapy, sets the standard for payment."
If this is a treatment that Medicare would pay for, then Blue Cross may have a problem. Of course, that would depend on whether Medicare indicates that it is an experimental approach or not.
-edit
http://www.proton-therapy.org/questions.htm
"Does proton therapy cost more than conventional forms of cancer treatment? Is it covered by most insurance plans?
* Nearly all insurance providers nationwide cover proton therapy as does the U.S. medicare program. Proton therapy costs more than conventional radiation, but generally less than surgery."
I had a sub-cranial chordoma about the size of a golf ball at the base of my skull just behind my eyes. 8.5 hours of surgery and 7.5 weeks 5 days a week of radiation therapy. Proton beam was not an option for me in 2005. I had what is called Cyber-knife. Covered by Pacific Care no questions asked.
BTW - at no time did my doctor ever mention that these tumors were considered cancerous. First I have ever heard of that. I will ask about that the next time I go in for a follow up.
http://www.cms.hhs.gov
The search on proton yielded 13 hits. What I'm reading is:
"Either #1, #2, or #3 must be present and
Either #4 or #5 must be present and
#6 must always be present.
#1. When dose constraints to normal tissues limit the total dose of radiation safely deliverable to the tumor with other indicated methods
#2. When there is a reason to believe that doses generally thought to be above the level otherwise attainable with other methods might improve control rates
#3. In circumstances when the higher levels of precision associated with proton beam therapy as compared to other radiation methods are necessary, i.e clinically relevant
#4. For the treatment of primary lesions, the intent of treatment must be curative
#5. For the treatment of metastatic lesions, there must be
a. the expectation of a long-term benefit (> 2y) that could not have been attained with conventional therapy
b. the expectation of a complete eradication of the metastatic lesion that could not have been safely accomplished with conventional therapy, as evidenced by a dosimetric advantage for proton beam radiotherapy over other forms of radiation therapy
#6. The patient’s record demonstrates why Proton beam radiotherapy is considered the treatment of choice for the individual patient. Specifically, the record must address the lower risk to normal tissue, the lower risk of disease recurrence, and the advantages of the treatment over IMRT or 3-dimensional conformal radiation. Dosimetric evidence of reduced normal tissue toxicity and/or improved tumor control must be maintained.
---
Covered illness includes: 192.2 MALIGNANT NEOPLASM OF SPINAL CORD
So, even for Medicare, there is criteria to be met.
I had a similar experience in 2007 in CA and reported my company to the Insurance Commission. Within two weeks, they discovered a one-time event reason that permitted them to change their mind about trying to make me wait 3 months after a lumpectomy for Stage III cancer, before they would pay for chemo.
Blue Shield tells everybody to drop dead, but that's after they take your money.
I'd love a class action lawsuit against them. They screwed me over and took a lot of my money in the process.
Oh, and don't try to make a late payment; they drop you immediately and send your check back to you with no grace period. That's the only way you get ANYTHING back from them.
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