By Myna - NorCal CarciNET Community Member
I have neuroendocrine cancer, a rare type of cancer that is chemo resistant with very few treatment options.
I went to Switzerland twice in 2013 for (PRRT). A special radiation treatment done in Europe but not currently available in the USA. It's been done there for over ten years, is well tolerated and a big help.
My tumors didn't grow for a year and a half.
I fought with Blue Shield HMO for reimbursement for that entire year and a half. They kept sending denial letters saying "chemo wasn't an emergency". After exhausting my appeals with Blue Shield, I went to the State and asked for an "Independent Medical Review". I sent in all my documents with a personal letter explaining that it was not chemo. I sent a letter on PRRT that the hospital in Switzerland had given to me. And pointed out that if I had breast cancer, I'd have chemo and Blue Shield wouldn't have blinked.
My Blue Shield HMO says they only pay for "emergency" treatments overseas. But the State of California defines "urgently needed services" as those necessary to prevent serious deteriorating of the health of a patient, resulting from an unforeseen illness, injury, or complication of an existing condition, including pregnancy, for which treatment cannot be delayed until the enrollee returns to the plan's service area."
They determined the PRRT treatment met the "prudent layperson criteria for urgently needed services"
The State sent my appeal to a radiologist who did his own research on my cancer and the treatment. His response was "Any prudent person would do what she did".
So they gave Blue Shield 5 days to pay. Three days later I had a check.
The State's Independent Medical Review is FINAL. So don't go there, until you have reached the end of your appeals with the insurer directly.