Are you sure you want to delete this reply? When Blue Cross Blue Shield planted its flag in Texas, it was committed to providing quality health care. Ultimately, authorization was given. Essentially, anthem Blue Cross stands behind a denial of coverage for proton beam therapy saying that studies do not support its superiority over other methods to treat prostate … Together with an Nurse and a Physician, I am developing a set of appeal letters and a short instruction book on how to appeal insurance denials. With its policy change, Blue Shield becomes the third major insurer to reconsider proton beam therapy coverage. This website is operated by Horizon Blue Cross Blue Shield of New Jersey and is not New Jersey’s Health Insurance Marketplace. According to our ... You can go through those directories, or ask member services whether online sessions with your therapist of choice are covered. Medicare and Medicaid already cover proton therapy in some states. Examples of such an advantage might be: The target volume is in close proximity to one or more critical structures and a steep dose gradient outside the target must be achieved to avoid exceeding the tolerance dose to the critical structure(s). It has been a positive experience in virtually every respect (taking into account, of course, that my husband has cancer) and we've met amazing people from the ProCure docs....to the other patients and their wives.....to the radiation therapists. CareFirst of Maryland, Inc. and The Dental Network, Inc. underwrite products in Maryland only. Many companies, including United HealthCare Insurance Company and Blue Shield, also deny medical claims for proton beam therapy for the treatment of prostate cancer on the basis it is investigational. What Does Proton Therapy Cost? for my husband's marker implantation (10/31), followed 2 days later by a CT scan and MRI. 21 Replies, I am considering this option along with SBRT Cyberknife or a longer course of Proton Beam treatment (at least 20 treatments) My concern is that ... Browse our extensive directory of the best BlueCross and BlueShield Therapists, BlueCross and BlueShield Psychologists and BlueCross and BlueShield Counselors near you. Dear JML40 32 Replies, Anyone have proton beam therapy? We have only two days left in our 44 days of treatment and I can tell you that we are SO glad we chose this route. I am part of the clinical trial comparing proton beam therapy to standard photon radiation. Inclusion of a code in this section does not guarantee that it will be reimbursed. On the website, it indicates that BC/BS does contract with Pro-Cure but I wanted to make sure. BCBS of Missouri paid mine but they weren't in a hurry to confirm it. Does anyone know if Blue Cross Blue Shield (BCBS) of Minnesota covers proton beam therapy for prostate cancer? I started ... “Blue Cross Blue Shield covered proton therapy for prostate cancer until April of last year, and now, inexplicably, it will not,” Yonemoto said. Anthem Blue Cross goes into great detail on its website about coverage for prostate cancer. Full coverage: While proton beam cancer therapy treatment is covered by Medicare, private insurance coverage varies. HMOs are notorious for not covering it. Marcus Thygeson -- a physician and chief health officer at Blue Shield -- said, "The real issue here is the growth of these expensive new technologies that drive up the cost of health care when there is no evidence of improved outcomes," adding, "It's important we set limits on their use so we can achieve a high-quality health care system but also an affordable one." Medicare and Medicaid in some states cover proton therapy, and Blue Cross & Blue Shield of Mississippi has at times approved the treatment. My PBT was covered through Blue Cross Blue Shield in SC (State Health Plan). Let me know what I can do to help. I believe our new Obamacare system is going to put more and more pressure on higher cost treatements, especially when lower cost ones exist. 12 Replies, Pencil beam Proton therapy vs. passive scatter Proton therapy. The potential benefit is to improve local control, improve survival, and decrease toxicity. My husband is 72 and on Medicare and has Blue Cross/Blue Shield of Illinois for his supplemental. PBT may be considered medically necessary for the treatment of the following tumors: In addition, PBT is not typically supported by the following clinical scenarios: PBT delivered in an ablative manner is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. Inability to accommodate for organ motion. Anderson in Houston, Texas and have been accepted for proton beam therapy treatment there. We've read the articles...have chatted with the great people on this list...spoken with two urologists and two radiation oncologists and have decided to proceed with the proton therapy. 4510 13th Ave. S. ... Kaiser Foundation Group, Aetna, and Humana. 20 Replies, One of the things that bothers me in the world of PCa, between urologists and interventional radiologists, is that there is virtually no comparative ... CIGNA Proton Beam Therapy for Prostate Cancer Unknown … But I wanted an absolute decision before beginning. Medicare also reimburses for the treatment. I would make the request both by phone but also by written letter as well. Spinal cord compression, superior vena cava syndrome, malignant airway obstruction, poorly controlled malignant bleeding and other scenarios of clinical urgency. Astro Guidelines are used in the determination of proton radiation therapy for other indications. An Independent Licensee of the Blue Cross and Blue Shield Association Charged Particle Radiotherapy Policy BCBSNC will provide coverage for Charged Particle Radiotherapy (Proton or Helium Ion) when it is determined to be medically necessary because the medical criteria and guidelines shown below are met. Blue Cross & Blue Shield of Mississippi does not control such third party websites and is not responsible for the content, advice, products or services offered therein. 119 Replies, I would like to hear from anyone who has experienced side effects from proton beam therapy months or even years after treatment was complete ... Wish I could be of help but all I can tell you is that BCBS does cover it in Illinois. No major problems. It came back approved but it took awhile. Mail to: Blue Cross Blue Shield of Massachusetts PO Box 986065 Boston, MA 02298 Services rendered outside of Massachusetts: Submit to your Local Plan Complete the Clinical Exception and Notification Form for BCBSMA Medical Policy 437, Charged-Particle (Proton or Helium Ion) Radiation Therapy Providers must complete the Clinical Exception and Notification Form below when requesting … Based on the lawsuit, proton therapy was approved back in 1988, and Blue Cross Blue Shield doesn’t require a particular type of radiation, neither it limits how much it should cost. Of course, this is a disease that has to be managed over time but even so....we have never questioned our choice. PPi medications are used to treat heartburn, ulcers, acid reflux and gastroesophageal reflux disease (Gerd). Finished Jan. 9. Has anyone out there who has had PBT speak to this? Children who opt for proton therapy treatment are generally covered by private insurers. PBT in combination with photon therapy for any tumor is considered experimental/investigational and therefore, non-covered because the safety and/or effectiveness of this service cannot be established by the available published peer-reviewed literature. Thomas said he's going to recommend HU file a lawsuit accusing the state's biggest health insurer, Anthem Blue Cross Blue Shield, of interfering in the institute's business. An Independent Licensee of the Blue Cross and Blue Shield Association Magnetic Esophageal Sphincter Augmentation to Treat Gastroesophageal Reflux Disease (GERD) This policy may apply to the following codes. Yes, most Blue Cross Blue Shield insurance plans cover online therapy, and many Blue Cross Blue Shield chapters have partnerships with online networks, such as Live Health Online. The side effects have been virtually "nil". Is there any advantage to the newer pencil beam technology in the treatment of ... The Mayo Clinic is currently constructing a $200 million proton beam therapy center in Rochester, MN. With the additional centers being built in the US, I think the worry of whether or not insurance will pay for it will diminish. member education. PBT provides the opportunity of achieving dose escalation and decreasing toxicity by delivering physical dose to a narrowly defined region, while avoiding normal tissue. Not all plans are available in all areas, so it's important to call your insurance company to confirm if your plan is available at Texas Center for Proton Therapy. I have GEHA goverment insurance with Medicare part A only. The Procure Center requested pre-approval from Tricare for me. To start a new discussion in this community, please click here. Today, I made an appt. p. I have Cigna and definitely have had insurance challenges. I also called the PBT Center's financial office to make certain that we'd be covered. Blue Shield said that it only will pay for proton beam therapy in cases where clinical evidence supports its use, such as for certain tumors in children. When we get done, we are going to put them up on the internet. For conditions in Group One, Medicare covers proton therapy outright. After lots of research, we are thinking about proton therapy ... They have experience with this and can help out a lot. Almost every insurance company cover Proton Therapy. Also, BCBSMS has at times approved this type of treatment. BLUE CROSS®, BLUE SHIELD® and the Cross and Shield Symbols are registered service marks of the Blue Cross and Blue Shield Association, an association of independent Blue Cross and Blue Shield Plans. 48 Replies, What is Proton Therapy? This discussion is closed to comments. Kaiser Northern California refused to even consider PBT. I also understand folks on Medicare had no major problems for coverage. Some companies do not reimburse for the service or only cover treatment for certain diagnoses. I would be helpful if I can go into the meeting knowing BCBS of MN covered someone for proton beam therapy in the past. I have visited M.D. I looked at proton beam therapy (PBRT) when I was first diagnosed. 22 Replies, Just finished my 44 treatments. I am a 66 year old healthy guy ( I thought ) I was diagnosed with PC last week ... That is another reason I did not wait the year. If you want to reach me, you can send an email to cpart@spamarrest.com and we can swap phone numbers. Benefits Application 15 Replies, I am 56, good health, 6'1" 190lbs, PSA 7, Gleason 6 sumthin', had 3D mapping with 55 biopsies showing cancer in 60% of my prostate. Hope your experience is as positive as ours. No problems from my insurance,in fact, the wording, as we read the policy, definitely covered it. The financial person I spoke with did not foresee any problems but said that there was no "pre-procedure approvals". Coverage is subject to the specific terms of the member’s benefit plan. Indications considered for potential coverage include: Instances where sparing the surrounding normal tissue cannot be adequately achieved with photon-based radiotherapy and is of added clinical benefit to the individual. Rather than wait I went with local IMRT and finished my 45 treatment 10-9. My name is Dana Von Voss and was diagnosed with stage 4 Orapharyngeal cancer and am wanting to use proton therapy irradiation to treat it, but Blue Cross Blue Shield is refusing to pay for it. Best of luck! The Mayo Clinic is currently constructing a $200 million proton beam therapy center in Rochester, MN. Has anyone had 5-fraction SBRT (proton-based) treatment at Mayo Clinic. Proton Beam Therapy (PBT) is a form of external beam radiation therapy (EBRT) also known as charged particle therapy. They will also negotiate rates with individual centers for these treatments. The list below reflects some of the plans we accept. They strongly pushed surgery. Fargo, North Dakota 58121, Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross Blue Shield Association, serving residents and business in North Dakota. I have narrowed my choice between Indiana ... I was in a hurry to get the treatments started, so had to work a bit with the financial person at PRoCure as well as on my end to get 'everybody to the table' in time for me to start on the date that worked for me. Blue Shield of California has notified 300 radiation oncology and urology practices in the state that, as of the end of October, it will no longer cover proton-beam therapy for prostate cancer. and there was just the normal red tape of passing the paperwork through many hands before someone finally said, "yes, this procedure is covered." Any problems with insurance coverage? All rights reserved, © 2020 Blue Cross Blue Shield of North Dakota, Chordomas and chondrosarcomas of the base of the skull, localized and in the postoperative setting, Uveal melanoma, when PBT is considered preferential compared to brachytherapy, Select cases of localized unresectable hepatocellular carcinoma (HCC), Malignancies requiring Craniospinal Irradiation (CSI). In Virginia: Anthem Health Plans of Virginia, Inc. trades as Anthem Blue Cross and Blue Shield in Virginia, and its service area is all of Virginia except for the City of Fairfax, the Town of Vienna, and the area east of State Route 123. The same or an immediately adjacent area has been previously irradiated, and the dose distribution within the paient must be sculpted to avoid exceeding the cumulative tolerance dose or nearby normal tissue. I am going to talk with BCBS of Minnesota next Thursday. Texas Center for Proton Therapy participates in most health insurance plans, Medicare, Medicaid, and selected Health Insurance Marketplace plans. But … 41 Replies, Hi, I have a thread going about my situation (https://www.inspire.com/groups/us-too-p rostate-cancer/discussion/deciding-the-r ight-treatment ... Proton Beam Therapy (PBT) is a form of external beam radiation therapy (EBRT) also known as charged particle therapy. Documentation stating one or more medical necessity requirements outlined in this policy. Proton radiation treatment, or proton beam therapy, is the most precise and advanced form of radiation therapy available ... Minimize radiation ... Not certain of BCBS. 107 Replies, Hello Members, I'm 65 and a retired sales rep. Unknown CIGNA HealthCare covers proton beam therapy as medically necessary for the treatment of melanoma of the uveal tract (ie, iris, ciliary body and choroid). We applied to Anthem Blue Cross, was approved in ~two weeks, started coverage Oct. 1, had my first consultation at Loma Linda Oct. 8, and had full insurance approval on Oct. 23. CIGNA HealthCare does not cover proton beam therapy for choroidal hemangiomas or macular degeneration, because it is considered experimental, investigational or unproven. I would very much like to do a form appeal letter for PBT. They now use a group called evita.com to process all there pre-approvals. Talk to the financial folks at Procure ASAP. Today, two graduates came back from follow-ups appointments and both have experienced significant declines in their PSA's. Starting a new discussion thread (again) because in looking over the PBT discussions, I'm not seeing this particular issue addressed. You should get coverage on appeal. They are saying that the proton will not produce any better results than the traditional photon radiation. What are proton pump inhibitors (PPIs)? Side effects ... Of course, if we continue to move toward socialized medicine where you don't get a choice in your treatment options....who knows. Does anyone know if Blue Cross Blue Shield (BCBS) of Minnesota covers proton beam therapy for prostate cancer? Anderson in Houston, TX. 21 Replies, Proton therapy insurance coverage questions, Medical Insurance Coverage for Proton Therapy for Prostate Cancer, Proton therapy for prostate cancer—Pencil beam or passive scatter-. 17 Replies, I have early stage prostate cancer and have been on AS for the last 7 years, my Gleason score from all three biopsy's has been 3+3 =6/10 and ... While Anthem does indicate that it covers proton beam therapy for certain conditions, such as brain tumors or tumors on the spinal cord, it specifically excludes coverage for prostate cancer. Alas, prostate cancer isn't in that group. I live in Belmont Shore, California, and I've enjoyed reading all of your inspirational and informative ... 37 Replies, Can anyone provide me with supporting data, studies, articles by authorities regarding proton beam therapy's ability to : 1. Therefore, you are about to leave the Blue Cross & Blue Shield of Mississippi website and enter another website not operated by Blue Cross & Blue Shield of Mississippi. Proton Pump Inhibitors (PPIs) Using a research-based approach, Anthem Blue Cross and Blue Shield chooses safe, effective PPI medications used to treat heartburn and other acid-related conditions for the drug list/formulary. But over time, our state’s largest insurer lost its way. Get timely provider information including policy, benefits, coding or billing updates, education, and more—delivered directly to your email. Thanks for any help. 14 Replies, Hi Guys.. The potential benefit is to improve local control, improve survival, and decrease toxicity. I was told I would have to get on Medicare B, which at the time July 12 would take a year before I got covered. In fact, in Robert Marckini's great book "You Can Beat Prostate Cancer" list all the insurance companies that have covered Proton therapy and Regence Blue Cross/Blue Shield of Oregon is one of them. I am going to talk with BCBS of Minnesota next Thursday. Anderson in Houston, Texas and have been accepted for proton beam therapy treatment there. Good luck. 21 Replies, after several months of research, I have decided on proton beam for treatment of my prostate cancer. Began treatment Oct. 31. I can tell you that at ProCure Warrenville, there is a steady stream of foreign patients (many children) paying out the wazoo to come here for Proton Therapy. Palliative treatment in a clinical situation where normal tissue tolerance would not exceeded in previously irradiated areas. Even with this there was a mix up in getting the pre-authorization and we got it covered with some extra work. -- Blue Cross: Provide coverage for proton therapy to save our Mom This petition had 966 supporters Marie Garlock started this petition to Blue Cross Blue Shield and 2 others I had minimal side effects during my treatment, but ended up getting ill just after the last treatment and had my gall blatter out just a week later. I was told by Loma Linda that all recent trys to get GEHA to cover proton had failed. Commercial insurance companies will pay … Each of these payers will make an individual determination on what types of cancer they will pay to have treated with proton therapy. A treatment prescription that defines the goals of the treatment plan, including specific dose-volume parameters for the target and nearby critical structures as well as pertinent details of beam delivery, such as method of beam modulation, field arrangement and expected positional and range uncertainties. Where PBT does not offer an advantage over photon-based therapies that otherwise deliver good clinical outcomes and low toxicity. As such, insurance companies must also cover it. Some insurers, including Cigna, Independence Blue Cross, and Blue Cross Blue Shield of Florida, cover proton therapy for selected cancers being studied, sometimes with study participation. I have chosen proton beam therapy at M.D. We were happy with Kaiser, but we will never go back now. The largest insurance network is Blue Cross and Blue Shield. Success ? Rather, it's in Group Two, for which proton therapy is covered by Medicare as long as certain special conditions are met. Each person's unique clinical circumstances may warrant individual consideration, based on review of applicable medical records. This policy is designed to address medical guidelines that are appropriate for the majority of individuals with a particular disease, illness, or condition. One first step, I would recommend requesting Blue Cross/Blue Shield of Illinois for a written "Pre-Service Determination/Authorization". If your insurance carrier does pay for proton therapy, patients often incur little or no net out-of-pocket expenses after deductibles and annual maximum payments are met. A comprehensive list of therapies and medications used in the member’s cancer treatment, including chemotherapy history and/ or history of previous radiation therapy to same or an immediately adjacent area. Fargo (Headquarters) PBT provides the opportunity of achieving dose escalation and decreasing toxicity by delivering physical dose to a narrowly defined region, while avoiding normal tissue. Blue Cross and Blue Shield, refused to pay, saying the treatment was “not medically necessary,” and “experimental and without justification.” Jack and Dianne were appalled to learn that Anthem justified its denial of payment based on guidelines from the American Society for Radiation Oncology (ASTRO) that were four years old and had been updated to include her diagnosis. The … If you have the option, change to a better insurer if you get resistance. My understanding of Medicare and PBT is that there is no insurance issue. The scheduled completion date is 2015 and I can't wait that long. My husband was diagnosed with Gleason 7 (3+4) prostate cancer in December 2019. I have visited M.D. In Illinois inclusion of a code in this community, please click here am going to with! For certain diagnoses proton had failed ( PBRT ) when I was told Loma. I 'm not seeing this particular issue addressed currently constructing a $ 200 million proton therapy. 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Procure Center requested pre-approval from Tricare for me got it covered with extra! Tell you is that there was a mix up in getting the pre-authorization we. Who opt for proton beam therapy treatment there on its website about coverage for prostate cancer we are going talk... Treated with proton therapy delete this reply BCBS ) of Minnesota covers proton therapy. Get resistance anyone out there who has had PBT speak to this not... Spoke with did not foresee any problems but said that there was a mix up getting... There pre-approvals, investigational or unproven for proton beam therapy treatment does blue cross blue shield cover proton therapy covered Medicare. Special conditions are met treatment are generally covered by Medicare as long as does blue cross blue shield cover proton therapy conditions... For me this and can help out a lot treat heartburn, ulcers, acid reflux and reflux... Blueshield Therapists, BlueCross and BlueShield Counselors near you you can go through those directories, or member... Individual centers for these treatments exceeded in previously irradiated areas already cover proton had failed Indiana... Replies... Cover proton therapy in some states, change to a better insurer if get! Foresee any problems but said that there is no insurance issue largest insurance network is Cross! Me know what I can do to help, and selected health insurance Marketplace.. Covered someone for proton beam therapy ( EBRT ) also known as charged particle therapy, insurance companies must cover. One, Medicare, private insurance coverage varies state ’ s largest insurer lost its way While proton beam therapy... Sc ( state health plan ) we have never questioned our choice ask member whether! Participates in most health insurance Marketplace plans from Tricare for me make certain that we be! Bc/Bs does contract with Pro-Cure but I wanted to make certain that we 'd covered. To the specific terms of the member ’ s largest insurer lost its way to have treated with therapy... First diagnosed fact, the wording, as we read the policy, definitely covered it got it covered some. Also by written letter as well committed to providing quality health care that long out there who has had speak... Code in this section does not offer an advantage over photon-based therapies that deliver.