What if my Insurance Won't Pay?
Insurance coverage for medical treatments and prescription drugs is a critical issue for carcinoid cancer/neuroendocrine tumor patients. The Carcinoid Cancer Foundation is delighted to partner with Laurie Todd, “The Insurance Warrior,” to bring you cutting-edge information about how to fight your insurance company if your claim is denied. Please visit this page often as we will frequently add new information.
Visit Laurie’s website, www.theinsurancewarrior.com, and learn more about this remarkable woman and all she has achieved for patients.
Excerpt 17:
Precedent: Call in the Troops
Precedent is cases where insurance companies have paid for your treatment before.
What is Precedent?
 Precedent is not you saying, "Many insurance companies have paid for this before."
Why should they believe you?
Precedent is not a list of insurance companies who have paid for this before. They won't believe you unless you give dates, and name names.
There are three different categories of precedent:
1. Cases where your exact same insurer has paid
2. Cases where other "branches" of your insurer have paid
3. Cases where other insurers have paid
Your doctor can't give you cases of precedent; there are laws against that. You are
going to have to dig for it yourself.
I have won cases with no precedent. It was like winning a boxing match with one
hand tied behind my back. I wouldn't advise it.
Do your work. Find cases of precedent, and put them in your appeal.
We rolled out our first six cases in Chapter 12—the cases where Acme of
Colorado, and five other branches of Acme, had paid for out-of-network treatment
with Dr. Sugarbaker before.
Let's look at the rest of the precedent). We will learn what precedent is, how to find
it, and how to make best use of it in your appeal.
SIXTY-FIVE CASES OF PRECEDENT
______________________________________________________________________________
Acme Insurance Precedent
Acme Insurance has funded this out-of-network surgery and HIPEC with Dr. Sugarbaker
six times in the last three years.
7. Sharon Smith (surgery date 9/06)
Diagnosis: mucinous adenocarcinoma of the appendix
Acme (CA) pays for out-of-network treatment with Dr. Sugarbaker and WHC.
8. Laurie Levy (surgery date 10/06)
Diagnosis: disseminated peritoneal adenomucinosis of appendiceal origin
Acme affiliate We Care Health signs single-case contract with Dr. Sugarbaker
and pays WHC.
9. John Jensen (surgery date 10/07)
Diagnosis: adenocarcinoma of the appendix
Kaiser affiliate Group Health Cooperative signs single-case contract with Dr.
Sugarbaker and pays WHC.
10. Kristin Kerrigan (surgery date 12/16/08)
Diagnosis: carcinoma of the appendix with peritoneal carcinomatosis
Acme (Portland) signs single-case contract with Dr. Sugarbaker and
pays WHC.
11. Martin Miller (surgery date 4/2/09)
Diagnosis: carcinoid tumors of appendiceal origin
Acme (CA) signs single-case contract with Dr. Sugarbaker and pays WHC.
12. Amy Andrews (surgery date 8/4/09)
Diagnosis: mucinous adenocarcinoma of the appendix
Acme (CO) signs single-case contract with Dr. Sugarbaker and pays WHC.
All major insurers
routinely pay for this treatment
All of the major insurers—including Blue Cross BlueShield, BC/BS Regence,
BC/BS Healthwise Plan of WA, United Healthcare, Aetna and Cigna—routinely
pay for cytoreductive surgery and HIPEC for appendix cancer with nonparticipating, out-of-area providers.
We understand that these are all different insurance entities. However, it simply
adds to the mountain of proof that expert cytoreductive surgeries are now
Standard of Care for this disease, and that all insurers recognize this, and have
been funding these treatments routinely for years.
SIXTY-FIVE CASES OF PRECEDENT
BC/BS Precedent
7. Tom Tennant (surgery date 12/00)
Diagnosis: mucinous adenocarcinoma
Horizon BC/BS pays Dr. Sugarbaker and Washington Hospital Center.
8. Debbie Diebold (surgery date 7/16/02)
Diagnosis: appendiceal cancer with carcinomatosis
BC of Illinois pays Dr. Sugarbaker and WHC.
9. Henry Hamilton (surgery date 5/03)
Diagnosis: cystadenoma with carcinoma of the appendix
BC/BS of Texas signs single-case contract with Dr. Sugarbaker and
pays WHC.
10. Frank Fulton (surgery date 7/04)
Diagnosis: mucinous adenocarcinoma with signet ring cells
Independence BC signs single-case contract with Dr. Sugarbaker and
pays WHC.
11. Mike Miller (surgery date 12/04)
Diagnosis: mucinous adenocarcinoma of the appendix
BC of PA pays Dr. Loggie and CMC.
12. Anne Atwater (surgery date 1/25/05)
Diagnosis: peritoneal mucinous adenocarcinoma with signet ring cells.
BC of CA pays Dr. Loggie and CMC.
13. Jim Jones (surgery date 3/2/05)
Diagnosis: peritoneal mucinous carcinomatosis w/ intermediate features
Independence BC pays Dr. Loggie and Creighton Medical Center.
14. Chris Connors (surgery date 5/05)
Diagnosis: mucinous adenocarinoma of the appendix
Horizon BC/BS pays Dr. Sardi and MMC.
15. Stephanie Simpson (surgery date 10/05)
Diagnosis: adenocarcinoma of the appendix
BC/BS of New Jersey signs single-case contract with Dr. Sugarbaker and
pays WHC.
16. Matthew Blaskovich (surgery date 12/6/05)
Diagnosis: mucinous adenocarcinoma
BC of New York pays Dr. Sardi and Mercy Medical Center.
17. Robynn Nussbaum (surgery date 6/06)
Diagnosis: adenocarcinoid tumors
BC of CA pays Dr. Sardi and MMC.
18. Robert Reynolds (surgery date 8/8/06)
Diagnosis: adenocarcinoma of the appendix
Independence BC pays Dr. Loggie and CMC.
19. Kristi Kandinski (surgery date 9/06)
Diagnosis: mucinous adenocarcinoma of the appendix
Capital Blue Cross pays Dr. Loggie and CMC.
20. Stefan Sandoz (surgery date 11/06)
Diagnosis: mucinous adenocarcinoma of the appendix
BC/BS of Massachusetts paid Dr. Esquivel and St. Agnes Hospital.
21. Linda Landers (surgery date 1/07)
Diagnosis: adenomucinosis with adenocarcinoma of the appendix
BC of Tennesee pays Dr. Mansfield and MD Anderson
22. Connie Chalmers (surgery date 4/07)
Diagnosis: mucinous adenocarcinoma
BC/BS of Washington signs single-case contract with Dr. Sugarbaker and
pays WHC.
23. Norma Nelson (surgery date 5/3/07)
Diagnosis: mucinous adenocarcinoma
Premera BC Lifewise Plan of WA signs single-case contract with Dr.
Sugarbaker and pays WHC.
24. Vickie Vincent (surgery date 5/08)
Diagnosis: disseminated adenomucinosis
BC/BS of Tennessee pays Dr. Bartlett and Univ. of Pittsburgh Medical Ctr.
25. Stephanie Sohnenberg (surgery date 3/08)
Diagnosis: mucinous adenocarcinoma of appendiceal origin
BC/BS of Rhode Island pays Dr. Esquivel and St. Agnes Hospital.
26. Diane Donaldson (surgery date 7/1/08)
Diagnosis: carcinoid tumors of appendiceal origin
Anthem BC/BS signs single-case contract with Dr. Sugarbaker and pays
WHC.
27. Candace Cleary (surgery date 8/14/08)
Diagnosis: adenomucinosis of appendiceal origin
BC/BS of Michigan pays Dr. Barone and Sharp Memorial Hospital.
28. Diane Carnacchi (surgery date 1/2/09)
Diagnosis: mucinous adenocarcinoma of the appendix
BC/BS of Michigan pays Dr. Sussman and Univ. of Pittsburgh Medical Ctr.
29. Gail Reed (surgery date 1/6/09)
Diagnosis: disseminated peritoneal adenomucinosis
Independence BC/BS signs single-case contract with Dr. Sugarbaker and
pays WHC.
Regence Precedent
30. Jill Jenner (surgery date 10/05)
Diagnosis: adenocarcinoma of the appendix
Regence BlueShield pays Dr. Barone and Sharp Memorial Hospital.
31. Matthew Matson (surgery date 6/07)
Diagnosis: mucinous adenocarcinoma of the appendix.
Regence signs single-case contract Dr. Sugarbaker and pays WHC.
32. John Jonas (surgery date 6/07)
Diagnosis: mucinous adenocarcinoma of the appendix (second surgery)
Regence signs single-case contract with Dr. Sugarbaker and pays WHC.
33. Darrin Danforth (surgery date 02/08)
Diagnosis: disseminated peritoneal adenomucinosis of appendiceal origin
Regence signs single-case contract with Dr. Sugarbaker and pays WHC.
34. Don Ditka (surgery date 7/11/08)
Diagnosis: mucinous adenocarcinoma of appendiceal origin
Regence BlueShield pays Dr. Matthew Holtzman and Univ. of Pittsburgh
Medical Center.
35. Mark Montalban (surgery date 9/16/08)
Diagnosis: disseminated peritoneal adenomucinosis of the appendix
Regence signs single-case contract with Dr. Sugarbaker and pays WHC.
36. Susanne Sandford (surgery date 11/25/08)
Diagnosis: adenomucinosis with carcinoma of the appendix
Regence signs single-case contract with Dr. Sugarbaker and pays WHC.
UHC Precedent
37. Barb Billingsworth (surgery date 3/11/03)
Diagnosis: disseminated adenomucinosis w/carcinoma of appendix
United Healthcare pays Dr. Sugarbaker and WHC.
38. Kevin Kendall (surgery date 2/18/04)
Diagnosis: mucinous adenocarcinoma of the cecum.
UHC (Oxford) signs single-case contract with Dr. Sugarbaker and pays WHC.
39. Becky Bonner (surgery date 11/04)
Diagnosis: adencarcinoid of appendiceal origin
United Healthcare pays Dr. Mansfield and MD Anderson.
40. Casey Crandall (surgery date 11/12/04)
Diagnosis: adenocarcinoma of the appendix
United Healthcare pays for Dr. Abel and UCSF.
41. Sandra Seeforth (surgery date 2006)
Diagnosis: adenocarcinoma of the appendix
United Healthcare pays for cytoreductive surgery and OON surgeon.
42. Barbara Benet (surgery date 6/06)
Diagnosis: adenocarcinoma of the appendix with signet ring cells
UHC (Oxford) signs single-case contract with Dr. Sugarbaker and pays WHC.
43. Gary Godsea (surgery date 9/20/07)
Diagnosis: adenocarcinoma of the appendix with adenocarcinoid
UHC signs single-case contract with Dr. Sugarbaker and pays WHC.
44. Glenda Grant (surgery date 2/08)
Diagnosis: adenomucinosis with carcinoma of the appendix
UHC signs single-case contract with Dr. Sugarbaker and pays WHC.
45. Siomara Sanderson (surgery date 5/08)
Diagnosis: mucinous adenocarcinoma of the appendix
UHC (Neighborhood Health) signs single-case contract with Dr. Sugarbaker
and pays WHC.
46. Michelle Mohaupt (surgery date 5/27/08)
Diagnosis: disseminated peritoneal adenomucinosis
UHC signs single-case contract with Dr. Sugarbaker and pays WHC.
47. Thomas Tinsdale (surgery date 10/15/08
Diagnosis: mucinous appendiceal tumor with pseudomyxoma peritonei
UHC signs single-case contract with Dr. Sugarbaker and pays WHC.
Healthnet HMO Precedent
48. Thomas Murray Thompson (surgery date 5/04)
Healthnet HMO member
49. Barbara Benson (surgery date 6/26/07)
Diagnosis: pseudomyxoma peritonei w/ carcinoma of appendix
Healthnet HMO of Oregon pays Dr. Sugarbaker and WHC.
50. Daniel DeMarco (surgery date 12/16/07)
Diagnosis: adenocarcinoma of the appendix
Healthnet HMO pays Dr. Sardi and Mercy Medical Center.
51. Jesse Jesperson (surgery date 6/02)
Diagnosis: carcinoma of the appendix
Aetna pays in-network rate for out-of-network surgeon Dr. Sugarbaker and
Washington Hospital Center.
52. Brenda Beckwirth (surgery date 11/30/04)
Diagnosis: mucinous adenocarcinoma of the appendix
Aetna pays for Dr. Loggie and Creighton Medical Center.
53. Tony Tancredo (surgery date 6/1/06)
Diagnosis: mucinous adenocarcinoma of the appendix
Aetna pays in-network rate for out-of-network surgeon
Dr. Prabir K. Chaudhuri and University of Toledo Medical Center.
54. Terence Torrance (surgery date 6/1/06)
Diagnosis: mucinous adenocarcinoma with peritoneal carcinomatosis
Aetna pays Dr. Jesus Esquivel and St. Agnes Hospital.
55. Nancy Newcomb (surgery date 12/27/07)
Diagnosis: adenocarcinoma of appendix with carcinomatosis
Aetna signs single-case contract with Dr. Sugarbaker and pays WHC.
56. Douglas Denny (surgery date 9/9/08)
Diagnosis: mucinous adenocarcinoma with carcinomatosis
Aetna pays Dr. Sardi and Mercy Hospital.
HMO Precedent
Kaiser Permanente also paid the patients’ airfare and hotel expenses.
57. Faye Fogerty (surgery date 9/01)
Diagnosis: adenocarcinoma of the appendix
Kaiser pays Dr. Sugarbaker and WHC.
58. David Duncan (surgery date 2/04)
Diagnosis: mucinous adenocarcinoma
Kaiser pays Dr. Esquivel and WHC.
59. Marlene Morganstern (surgery date 6/05)
Diagnosis: adenocarcinoma with carcinomatosis
Kaiser pays Dr. Esquivel and St. Agnes Hospital.
60. Dawn-Monique Minton (surgery date 6/16/05)
Diagnosis: mucinous Cystic Appendiceal Neoplasm
Kaiser pays Dr. Esquivel and St. Agnes Hospital.
61. Laurie Todd (surgery date 10/05)
Diagnosis: adenomucinosis with carcinoma of the appendix
Group Health HMO signs single-case contract with Dr. Sugarbaker and pays
WHC.
62. Miranda Miller (surgery date 10/05)
Diagnosis: adenocarcinoma of the appendix (first surgery)
Group Health HMO signs single-case contract with Dr. Sugarbaker and pays
WHC.
63. Michael Montgomery (surgery date 11/05)
Diagnosis: mucinous adenocarcinoma
Group Health HMO pays Dr. Loggie and CMC.
64. Norman Nelson (surgery date 4/06)
Diagnosis: cystadenoma of the appendix
Kaiser pays Dr. Graves at Sutter General Hospital.
65. Wendy Wood (surgery date 5/06)
Diagnosis: adenocarcinoma of the appendix
Kaiser Permanente pays Dr. Jesus Esquivel and St. Agnes Hospital.
"But they called my treatment 'experimental'," you say, "How could they have paid
for it before?"
If you are asking for a halfway legitimate medical treatment—your insurer has paid
for it many times before. You will write a blockbuster appeal, and get it approved
for you. The next patient who comes along will have it denied as "experimental,"
and will have go through the same process all over again.
The only person who could possibly think that this is acceptable is a person who
works at an insurance company.
My Precedent List
This is a version of my real precedent list for appendix cancer—with all names
changed, of course. Appendix cancer was the disease that I had, and I have been
actively collecting cases for four years. I really do have sixty-five cases.
Please don't be alarmed. I don't expect you to find sixty-five cases.
How many cases do you need? Enough to win your appeal. In other words—more
than one, and as many as you can.
I have seen appeals where people only used one case of precedent. Guess what the
insurance company said? "Yes, we did pay for it once—but we didn't mean to. We
paid for it by mistake, " or, "He had a different plan than you do," or, "That was a
one-time deal."
Find at least six cases of precedent, and aim for an even dozen.
Precedent FAQs
1. Where do I find precedent?
Do me a favor. Don't call your doctor's office asking for precedent. There are
serious medical privacy laws (HIPPA), and they can't give it to you.
How I wish it were that easy. Finding cases where insurers paid before is very
labor-intensive. However, it is well worth the effort.
We find precedent by joining online groups for our disease/condition, and
putting out the call.
Let's say you have carcinoid tumors, you have requested an external pump to
use with the drug Sandostatin, and Acme has denied it as "Experimental for
this use." You have read Acme's Medical Policy Statement about the pump, you
have studied their definition of "Experimental," and you have familiarized
yourself with Acme's appeals procedures. Now it is time to join an online group
for carcinoid tumors, introduce yourself, and put out the call.
Online patient support groups come in many forms: websites, listservs, and
Yahoo groups—to name a few. Find the most active groups, with the most
members, and post the following:
"My name is John Q. Patient, and I have Acme Insurance. Acme has denied my request for an external pump for Sandostatin. Has your insurance company paid for it? If so, I need your:
1. First and last names
2. Name of insurance company
3. Date of treatment
4. Doctor's name
2. What is precedent?
Precedent is not you saying, "Many insurance companies have paid for this
before," and precedent is not a list of insurance companies that have paid.
Why should they believe you?
Remember the power of names. You are going to have to prove that they have
paid before by giving dates, and by naming naming names.
3. Will people give me their private information?
I have never had any fellow patient withhold it. We need and want to help each other.
4. Will I get in trouble for putting private information in my appeal?
HIPPA is a group of federal laws ensuring that medical information is kept
confidential, as it moves through the healthcare system. Violation of HIPPA
laws brings very serious consequences for the entities that are covered by them.
Who are the entities that are covered by HIPPA? Doctors and other medical
providers, health insurers, and third-party administrators (companies that
handle insurance billing).
I am not a doctor, I am not an insurance company, and I am not a third-party
administrator.
I am a cancer survivor, gathering cases of precedent to help myself and other
cancer survivors. I ask for their information to use in appeals, and I get their
approval to do so.
I seriously doubt that Acme Insurance is going to sue me for a HIPPA violation.
5. What if there is no precedent for my insurance company?
Take another look at my sample precedent list. First, I list the cases where my
own insurer has paid before. Next, I list the cases where other "branches" of
my insurer have paid. Finally, I roll out the cases where other large insurers
have paid, and where HMOs have paid.
Obviously, if you can find a case where your own insurance company—in your own
state—has paid, that is the most powerful type of precedent.
However, I throw in all precedent that I can find, at all times, with the following disclaimer:
"We understand that these are all different insurance entities. However, this extensive list of approvals simply adds to the mountain of proof that this treatment is now standard of care for this disease."
***********
When it comes to precedent—use what you have. And use it to best advantage.
Your insurer denied your treatment because it was "Experimental"? Through your
own due diligence, you have managed to discover that they have already paid
for it a dozen times. As a matter of fact, they paid for it last week.
If nothing else convinces you to realize that the Insurance Emperor has no clothes,
precedent should. There is no substance behind their denials. It is all bluff and bluster.
Here, in Sample Appeal Class, I am teaching you how to see through their bluff
and bluster. First, clear away all the propaganda. Then, learn to fluff up your feathers,
look big and intimidating, and turn the insurance company's own words to your advantage.
To purchase Laurie’s book and CD, click here: http://theinsurancewarrior.com/thebookandthecd.html
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