Oxford Insurance

[jcm]

I finally decided on CyberKnife treatment for a 1CM AN and Oxford is telling me they don't recognize it as a treatment. What should I do?

[sgerrard]

I just emailed a friend, for their friend, about Cyberknife and insurance, so I am pasting part of that here, in case it helps. First a comment, then some links and info.

An insurance company will typically say no if a patient calls up on their own asking for approval. They simply can't base an approval on that. They are much more likely to approve when presented with a formal case from a medical facility, complete with all relevant documentation. A patient can facilitate that by finding appropriate contacts at both the insurance company and the medical facility, then getting and faxing copies of everything to both parties.

There are of course cases where the insurance company still says no:

CBS report on denial of Cyberknife by Blue Shield, and eventual acceptance on appeal:
http://cbs5.com/investigates/CyberKnife.blue.shield.2.716740.html

One of many discussions of the subject on the Cyberknife patient support group forum:
http://www.cyberknifesupport.org/forum/default.aspx?f=16&m=19808

From my own experience, a quote from a post I made at the time:

"I got the call today from Stanford, the insurance company has approved having Cyberknife. I am on for Sep. 10th. The scheduler Scarlett said that what helped the most was when I faxed the RN at the insurance company copies of all the reports - the radiologist report on the MRI, the audiogram, the vestibular lab tests, the radiation oncologist evaluation, and all emails from Dr. Chang at Stanford."

This issue has come up before. There are various cases in the news and on the Internet. Swamp your insurance company with information on Cyberknife; get every doctor you know who has heard of CK to write to them; get the radiation oncologist and/or neurosurgeon to send them indignant emails and phone calls. Be sure they have copies of every medical report and examination and diagnosis and treatment recommendation.

Maybe something will budge them.

Steve

[goinbatty]

Check out this link:
http://www.cigna.com/customer_care/healthcare_professional/coverage_positions/medical/mm_0110_coveragepositioncriteria_stereotactic_radiosurgery_srs.pdf

Hope this helps,
Sandra

[sgerrard]

That's a great reference, Sandra, thanks for posting it. It should give any reluctant insurance company all the information they need to make the right decision about covering CK.

Steve

[Joef]

Not a treatment ?? ... jeez...

Their corporate offices are in the next town over ... I actually went for a job interview once... and they turned me down .. they obviously don't know a good thing when they see it 

[HeadCase2]

  Sandra, thanks for the link, this document has a lot of good information.  JCM, you could start by providing Oxford with the billing codes from the document Sandra kindly provided.  They should be able to look things up from the billing codes.  I believe the billing codes are universal and used by all insurance companies, so they would probably have a hard time saying they "don't recognize it as a treatment".  It's bad enough receiving an AN diagnosis.  We know what you're going through. You shouldn't have to battle with the insurance company.
Regards,
  Rob

[goinbatty]

Another little bit about coding.  There are so many layers to insurance.  Let's just say the claims folks process claims, hopefully anyway, using the codes on the claims and applying that to your benefits/coverage.  That claim is only as good as the person entering the coding from the provider.  You would be surprised at the errors that occur there.  And with denials, the insurance company should provide you with the reconsideration/appeals process. 
Good luck!
Sandra

[jcm]

Thanks for all your advise, you have given me a starting point. Hopefully I will post good results in the next week or so, and not have to postpone my treatment scheduled for the 2nd week of July.

[jcm]

Good news, I got a call today from the Cyberknife scheduler at Stanford and she said it was approved! Scheduled to start treatment on July 7th. Thanks for all your advise and encouragement.

[Mark]

Congrats jcm!  never a doubt in my mind. The folks at Stanford have always been pretty successful in working with insurance companies on getting CK approval. Best wishes for a great treatment

Mark

[sgerrard]

Must have been Scarlett White. She is a force to be reckoned with. 

That's great news, jcm. Have a good trip and a great treatment. Bye bye AN.

Steve