Medicare refusing chemotherapy?

[seanmdevine]

I haven't been here in a while, I suppose it is because things have been going ok with my father. He has been through 4 rounds of chemo and was scheduled for the fifth this past Monday. The Friday before the oncologist's office called to tell him that his appointment was put on hold due to the fact that his insurance (Medicare) had not approved it thus far. It still has not been approved and his visit to the oncologist yesterday revealed that it most likely will not be approved.

1/ Did they know that this would happen and still scheduled the bloodwork and CT scan anyway?

2/ Is this a normal occurrence for a not curable SCLC patient? To be refused chemo after a set amount of treatment?

His insurance says it will only pay for 4 rounds of chemo. If he doesn't get some sort of treatment I suspect he will deteriorate rather quickly. His oncologist has a plan for some other treatment that my dad couldn't remember what it was exactly. I'll find of from my stepmom today. I'm not sure how to proceed.

 

Thank you,

Sean 

 

[Tom Galli]

Sean,

Something about your dad's insurance denial is unusual. Given, the standard of care for extensive stage small cell lung cancer can be 4 infusions of chemotherapy. The most common pairing is Cisplatin and Etoposide. But a relatively new systemic treatment called immunotherapy is now becoming a more common method. The name of the immunotherapy drug is pembrolizumab. This can be given alone or in combination with Cisplatin and Etoposide.

I can envision an insurance problem if a doctor wants to continue a 5th or 6th infusion of Cisplatin and Etoposide alone, but if the doctor has a good reason for doing so, Medicare will likely agree but the doctor needs to engage with Medicare to communicate the reason.

Stay the course.

Tom

 

[seanmdevine]

Thank you for your reply Tom. I sincerely appreciate it. I think the problem is exactly as you described. Medicare will not approve a fifth chemo treatment of Cisplatin and Etoposide. His oncologist is pushing through something else that may or may not be chemo and/or immunotherapy. The problem is that he doesn't remember exactly what she said. I'll get to the bottom of it when I have a day off tomorrow. Do the insurance companies not approve chemo after 4 treatments because it will not cure him? The prognosis is not good, I get it, but still it seems a bit inhumane. I'm curious what you think the reasoning is?

 

Thank you,Sean

 

[Tom Galli]

Sean,

I wouldn't have any idea why insurance companies behave the way they do. Well, in a general sense, I do--money. Insurance companies feel that all premiums paid belong to the company and therefore don't like paying for patient care. And, indeed insurance companies are about the most inhumane organizations in society. They've always been so.

Stay the course.

Tom

[Kamoto]

Medicare reimburses nearly all of the 16,600 per month Tagrisso target therapy drugs cost.  So denying a round of chemo, which is cheap in comparison, doesn't sound right.  Take Toms advise.