My last chemo treatment was January 31st, and my next was scheduled for February 14th. So I was surprised to receive a message on my voicemail on Wednesday that my appointment had been cancelled because the insurance hadn’t approved it yet.
What??
I spent an hour on the phone three weeks ago getting this all squared away. I had a letter from the insurance company stating I was covered through May 10th.
What the hell.
I called back to speak with the woman who left the message, a medical assistant. I told her about the letter and said that I was bringing it to my appointment today. (I had tried to upload it to the doctor through myChart but it was too large.) I gave her the call reference number I was given. She said she would follow up on that and call me back in about an hour. I said I was planning to come in for my appointment as scheduled. She said, “Well, if you have a letter from your insurance, we’re not going to turn you away.” Ha. Good one.
She didn’t call me back as she said she would, but I headed to my appointment anyway even though it was already taken off the schedule in myChart.
I recapped the situation for the receptionist and gave her the letter so she could make a copy. “Oh, we already have this, we don’t need a copy.” What?? Then what the hell was the deal?? She said the medical assistant would come speak with me.
She came out and said that the letter didn’t specify that my insurance was covering the chemo. The letter stated:
“The denial for J9047 has been overturned and approved for benefits 5/10/2023 – 5/10/2024 (12 months),” followed by the call reference number.
Seemed pretty clear to me.
The medical assistant said that “approved for benefits” doesn’t mean chemo. She said the oncologist requested treatment from 01/01/2024 – 01/01/2025, and it was denied. He was scheduled for a “peer-to-peer” call next week to discuss with the person or panel or whomever denied the claim.
Okay but *I* had a letter in my hand (that I was showing her) stating I’m covered through May 10th. We could deal with the other stuff later. I’m covered for chemo TODAY. She said the letter wasn’t specific enough, and if I opt to have chemo today and payment is denied by my insurance, I’ll be responsible for the cost.
At this point, I was pissed. I said, “You know what? I’m seriously over all this. If I hear back from you, great, and if not, well, it’s been nice.” And I just walked out.
When I got to my car, I called my insurance company. I apologized right up front to the poor man on the other side of the call. I told him I was really frustrated and that I would try not to take it out on him. He was very nice (every time I’ve called BCBS, they have ALL been very nice). I explained the situation, and he pulled up the letter that was sent to me stating I was covered through May. “And your doctor’s office wouldn’t see you today?” “Nope.”
He put me on hold and while he did, I googled the procedure code J9047. That is the code for injection of carfilzomib. Carfilzomib is the generic name for Kyprolis. The medication I’ve been on for three years.
So the letter says that they have overturned the denial for the injection of Kyprolis through 5/10/2024. Meaning I’m approved for Kyprolis injections though 5/10/2024.
Why is this letter not clear enough? And if I could google that procedure code in 15 seconds while on hold with a customer service rep from BCBS, why couldn’t the doctor’s office do the same thing at some point over the past three weeks? I GAVE the doctor the call reference number on January 25th. He said he passed it along to the appropriate staff.
The rep from BCBS said he was going to call the doctor’s office right then with me on hold. I told him to ask for the medical assistant and gave him her name. He came back on the line and said he couldn’t speak with her as she was with a patient, but he left a detailed message with the receptionist stating that I *AM* covered for Kyprolis through May 10 as specified in the letter. And he gave her and me a new call reference number for this call. This again took nearly an hour, with me sitting in my car in the parking lot. I thanked him for his help.
I messaged the doctor before I left and gave him the information from the call. He hasn’t responded.
As I understand it, there are three things going on:
- There are those four dates from January to April 2023 that were deemed “experimental” and “investigational” and were denied by my insurance company.
- An appeal was filed at some point by my doctor (not for those dates above) which caused them to overturn the denial, which resulted in the letter I had for treatment through May 10th.
- The oncologist recently requested approval for treatment through January 2025, which was denied. For this he has the peer-to-peer call scheduled for next week. (I didn’t know about this until I was at the office on Wednesday but the next day, I received a letter regarding the denial.)
At this point, I don’t think there’s anything I can do. I’ve already filed an appeal, which I’ve heard NOTHING about, by the way. Per their own protocol, they were supposed to contact me within 72 hours of receipt of the appeal. They received it January 19th. I’ve heard nothing, not a word. BUT I didn’t think too much about it since I got the approval through May. But at some point in the near future, I’m going to have to call back on that and follow up I guess. I’m so tired of doing all this by phone. I want to be face-to-face with someone and have this conversation. It’s probably a lot easier to deny people health care when they don’t have to look you in the eye when they do it.
So… I don’t know where things stand at this point. Supposedly someone is going to call me after the doctor has his call next week. But what about the call the rep from BCBS made to the office? What’s going to come from that? And why did they let me keep my appointment on January 31st but not on February 14th? (I didn’t even think to ask that question when I was in the office.)
And, again, why cherry-pick four dates to deny coverage when I’ve been getting the SAME medication for the SAME disease for the past three years? Why approve treatment for a 12-month interval from May 2023 to May 2024 but then deny treatment for January 2024 to January 2025? The SAME medication for the SAME disease?? And it’s already been approved for part of that time. I can’t imagine this even makes sense to the insurance company. It’s just bullshit. I’m over it.
Other very minor medical mishaps this week: I requested that my PCP’s office send a prescription for cholesterol medicine to Walgreens as I was out of refills. I got a message from the nurse that it had been sent. I waited a few days but nothing from Walgreens. So I messaged the doctor’s office again and gave them the address of my Walgreens. Another message that it had been sent. Still nothing from Walgreens. Yeah, the doctor’s office sent it to a completely different pharmacy. Not even a Walgreens. Great.
Because of the Trulicity shortage, my endocrinologist said she was going to switch me over to Ozempic. I called my insurance company on January 31st to inquire if she needed to submit a prior approval for the drug as she did for Trulicity. Yes, she did. They faxed it to her office that day. I messaged her and told her they had faxed the form. She needed to fill it out and send it back. I’m sure she’s very familiar with this process.
A week later, it still said “waiting for insurance approval” on the Walgreens app. I called my insurance again. Nope, the doctor hadn’t sent back the form. I messaged her again, requesting again that she send back the form and to let me know when it was sent. Another week went by. Nothing. No form and no response from her.
So I called the insurance company again yesterday just to be sure the form wasn’t sent it. Nope. I called her office and told the receptionist this information. Interestingly, she was able to see the messages I had sent to the doctor on myChart. (Hmmm. That’s kind of odd, no?) She said she would escalate the message and “hopefully” the form will get sent over soon. I mean I KNOW the doctor isn’t the one who actually sends the form. But it’s been two weeks since BCBS sent the form over, and it’s now been a month since I’ve last taken any diabetes medication. That’s not the way it’s supposed to work.
Needless to say, I’m definitely over doctors this week.
Low, Low, Low 