Help....Ins denial for annual DEXA payments
 

My insurance has denied coverage for annual DEXA (bone density studies). I am on AI (Femara), have osteopenia, and my oncologist said annual DEXA is recommended.
Any suggestions for ammunition for my appeal would be appreciated.
Thanks...

Any idea how much the scan would cost? I know some hospitals have pretty generous payment schedules available.

Rich, around $500. I know there are many whose insurance will cover annually. Normally the ins will cover bi-annually without hesitation.

Harry - lawyer in me talking here - what is the reason given to you for denial?

Rebecca

Harrie - you have to appeal. Insurance companies often deny as a matter of process, expecting that you won't appeal... when they do respond to the appeal, read their letter very closely - it should reveal information that will give you clues as to what you need to do or what your doctor needs to do differently to code it for approval.

Quote from denial letter
 

Rebecca, this is what they wrote:
" According to HMSA's medical policy for Bone (Mineral) Density Studies, follow-up studies performed more frequently than once every two years is limited to individuals on glucocorticoid (steroid) therapy equivalent to 5.0 mg or more or prednisone per day for more than three months, with precertificaton. In addition, bone density studies performed less than 24 months do not adequately reflect bone turnover, do not improve health outcomes, or decrease the incidence of fractures."

A friend of mine (same ins) is also on Femara and has annual DEXAs taken and the insurance covers. She also has osteopenia.

Maryanne

You need to appeal with a letter from your doc stating you are in breast cancer treatment, including research and evidence about Femara, osteopenia/porosis and b/c treatments. Also, when you appeal, cc: your state board of insurance.

Maybe your doc should talk to your friend's doc to see how they got it approved.

appeal
 

Oh yes, I definitely do plan to appeal. I just emailed my onco for a statement from him. I never thought about the CC to the St Bd of Ins. Will have to do a bit of research to locate that address.

If all else fails, get advice from the Cancer legal Resource Center..You don't have to be from California:

Cancer Legal Resource Center

Regards
Joe

Harrie,

It seems to me that the problem is in the word "recommended" in your onc's letter. A stronger word, such as "required", "medically necessary" or equivalent is suggested. Our lawyer member certainly hit all points in her dissertation. Tell the insurance you are on Femara, an A.I. inhibitor, which is medically proven to be a bone density reducing medication. Constant and annual bone density test is mandatory. Without continuing monitoring, the patient may have reached the verge of bone fracturing status without knowing it. The insurance company that denied the bone density test is then liable for the consequence of bone fracture. Sending a copy of the letter to the state medical insurance office is an excellent idea. Good luck.

I just got done writing my first draft of my appeal. Thank you for all the suggestions and for the recommendations on my wording. Ann, I will be sure to write much more assertively then how I had initially planned.
By the way, I tried googling "state board of insurance" for Hawaii and I did not find anything in particular that I could use to address this issue.
Do all states have a State Bd of Ins?

Maryanne

Harrie,

I think this is what you are looking for. I had to find it for Virginia previously, so Hawaii wasn't much different. Hope this helps.
http://hawaii.gov/dcca/areas/ins

Thank you Sassy. So I guess I should CC a copy of my appeal letter to the Dept of Commerce and Consumer Affairs, the dept that regulates insurance issues, right?

Harrie,

If you wish to formally file a complaint, there is a form to include.

http://hawaii.gov/dcca/areas/ins/con...nsurer_or_plan

If you don't wish to file a complaint, but want your letter to be on record and just let the insurance company know you plan to pursue the matter, I think I would cc: Commissioner, Department of Commerce and Consumer Affairs.


Good luck!

Well Folks, I appealled and lost. My ins will not pay for annual DEXA, but will only pay for once every 2 yrs. This is what was said:
"...scientific evidence does not support improved health outcomes with yearly monitering of bone mineral density in a patient on aromatase inhibitors being treated with a bisphosphonate, nor is it the standard of care.
......in review of your case, the Committee discussed the change to the policy regarding the use of annual DEXA scans for patients treated with aromatase inhibitors. It was noted that, because of the potential of bone loss, annual scans were done until research and a formal policy review concluded that given the nature of the bone loss and the specificity and reliability of DEXA scan, scans done more frequently than 24 months were not useful to determine the course of treatment.

So I am stuck with the +$500 DEXA.

Hi Harrie,

Sorry you lost the appeal. I am wondering though why your doc recommends yearly DEXA's. Has he explained what benefit you would get from annual scans?

My second DEXA after 2 yrs of Arimidex & Zoladex showed osteopenia in the lumbar region, but 18 months later, there was a slight improvement. I started reading about it and found an article that mentioned that most of the bone loss stops after 2 years on an AI. I don't remember whether this was the case for all AI users. Unfortunately, I can't find the article.

I think my bone density improved as a result of more exercise. You may want to look into that. A helpful site would be: http://www.strongwomen.com/strongbones/sboverview.htm

DEXA scans don't improve one's bone health. They just monitor bone loss. Are you taking a biphosphonate? I can't, because of the risk of Osteonecrosis of the jaw. I'm already having trouble with dental infections. So the slight increase in bone mineral density is probably the result of of increased exercise and taking calcium, magnesium and vit D.

Love

Jacqueline

Harrie,

Sorry to hear that you are out the $500 for the DEXA. When I saw my new onc for the first time we discussed my osteopenia and continuing with Zometa - he supported that 100%. When I asked about scheduling another bone density test - after one year on Femara and two infusions of Zometa - he said that he does them every two years, stating the guidelines and added that it takes time to build bone. I am okay with that - at least for now.

You did your best and sometimes logic doesn't fit with insurance
 

Gosh, Harrie, it would have been so nice if they had covered your DEXA, especially since you articulated your reasons so well that the medication you are taking causes bone thinning and is necessary for your medical condition. You did your best and at least you know it will be covered after the two-year timeframe.

Vicki Z.

Oh well...thats the way it goes. To look on the bright side, I am thankful that it probably isn't really critical or necessary for me to have it done annually.

Jacqueline, I do exercise regularly....like 6 days a wk! I do yoga which is wt bearing (my wt), I do wt resistance with machines, and either aerobics or the treadmill. Yes, I know...call me a fanatic.

Thanks everyone! Blessings to you all!!