Oncotype: Ins denial

[harrie]

For those of you who had the Oncotype DX testing done, could you tell me if your insurance paid for the test?

My insurance denied payment based on the rationale that there is no scientific evidence that the Oncotype Dx test improves health outcomes nor is it the standard of care. They said while the National Comprehensive Cancer Network has extensively researched the tx of bc, including the role of Oncotype dx testing in risk stratification and tx decision making for early-stage invasive bc, a definitive recommendation has not been made for its use in this clinical setting. They noted that medical literature reflects that further studies are required to determine the role that prognostic marker studies such as the Onco dx have in guiding tx decisions for pts with early-stage invasive bc. Therefore the test is considered investigational and not a covered benefit.

Maryanne

[Becky]

Keep pushing your insurance company and have the Oncotype DX company push too. There is NO ONE I have met who had this test have insurance cover it from the get go. But all eventually succeeded in getting it covered by their insurance via appealing. Insurance will try to not pay for such things (wigs included) but they eventually will.

[Shell]

Maryanne-

I hope insurnance pays for it for you - keep pushing!

But as I didn't have the test done, I was nost intrigued by Becky's answer about the wigs - I never pushed my ins. co. and ended up paying for it myself. My hair is rapidly thinning on abraxane, and am wondering if I should push the ins co to pay for a new wig...

Regards,

[tousled1]

Regarding insurance not paying for wigs - this is the first time I've heard that. I thought that if your doctor wrote you a prescription for a cranial prothesis your insurance would pay for it under durable medical products. I would check your insurance coverage. I know my insurance pays for dural medical products but only 80%. This also applies to any sleeves required for lymphedema and breast prothesis. Most insurance companies have durable medical product coverage of some sort.

I had a script for a wig and my insurance still rejected paying, but I really didn't mind, as aside from $750, it was the only other thing I paid for in my first year of treatment.
I wonder if I should have questioned the decision not to pay.

[Becky]

I questioned, questioned, questioned about my wig. I was even told by my insurance they covered it (at certain places) but since I lived over 150 miles from the closest "approved" place, I could go anywhere I wanted. I was smart enough to get the person's name. Then they denied they said this but the conversation was taped on their end. It took 8 months but I got my money. If this happened to 1000 other people who didn't push for what they were entitled to, the insurance company makes 500,000 dollars (and it goes right to their bottom line).

Push

[Sheila]

I just got mine, and I called the insurance company to verify coverage, they said the script from the Dr. needed to be coded with a diagnosis, state Cranial Prosthesis, and the reason was hair loss due to chemotherapy. My insurance covered 500.00 no matter where i went...the one I got was 700.00 so it cost me 200.00 for human hair. They have already paid and I just submitted the bill last week.

[Jean]

Maryanne,
Do not give up....The company Genomic Health will help you.
They will get in touch with your insurance company and fight
for your coverage. My insurance paid the entire bill. It is
so wrong that on top of fighting cancer that anyone has to
fight for coverage for tests.

This test is now being used at Sloan.

Good Luck
Hugs,
jean

[suzan w]

Yes, Genomic Health will fight for you!! I had a wonderful woman advocate there (will try and look up her name) who fought on my behalf for over a year with FL blue cross and after many denials, they finally PAID!!! When I called Genomic to tell them that I had received a check from Blue Cross for the entire cost of the test I could hear all the people in the background cheering!!! It was a GREAT DAY!!!

[harrie]

Congratulations Jean and Susan in winning over the ins co! My insurance company is Hawaii Medical Insurance Assoc (HMSA) whose parent company is BlueCross/BlueShield. I have dual PPO, but so far I have run into my disappointments with this company. Earlier this year, headline news was the huge bonuses the CEO's from HMSA were paid.

[Joe]

Genomic Health is pleased that many payers have established favorable coverage policies for Oncotype DX, representing more than 125 million lives covered. These payers include Medicare (through a local coverage decision developed by the National Heritage Insurance Company which applies to all testing billed by our California facility), United Healthcare, CIGNA*, Aetna*, Kaiser Permanente, Health Net, Humana and many others. We are committed to expanding coverage for the Oncotype DX assay and continue to work with all major plans across the nation to establish favorable policies.

Through our Genomic Access Program (GAP), benefits investigations may be performed to provide your patients information about their specific coverage and potential financial responsibility. Some insurers may require a prior authorization prior to the processing of the patient's specimen. The GAP team can help facilitate this process for you. If coverage is denied our GAP team can appeal this denial on your patient's behalf. However in those cases where all appeals are exhausted and the claim is not fully paid, the patient will ultimately be responsible for any balance remaining on the invoice. Genomic Health provides a generous Financial Assistance Program for patients with financial hardship and a program for uninsured and underinsured patients. The reimbursement professionals at Genomic Health will do their very best to obtain coverage for this test, but they cannot guarantee success.

For questions concerning reimbursement or financial assistance, please call Genomic Health Customer Service at 866-ONCOTYPE (866-662-6897).

Regards
Joe

[Mary Anne in TX]

Keep pushing and ask your doctor to write a letter requesting why he wants it. They will resist everything they can. Fight them as you fight for you! Makes ya feel good!! ma

[Bev]

Try writing or emailing your state insurance board. Your doc will also have to send a letter as to why it was necessary. At the very least, CF will look into things. I was successful getting H covered this way back in the day.

Best wishes, BB