How Do You Get Exactly The Treatment You Want?
This is the actual
document Karl used to get exactly the type of treatment for Jean -- after the
PET scan showed no trace of cancer. After that scan, Jean could still not
swallow. Karl learned more and more about the treatments which could solve
that problem -- the below presents that information before even a final decision
was made by Jean.
This message was
successful -- the insurance company authorized exactly what we wanted.
Click HERE for the scanned images of the two insurance
approvals in late September 2004.
One of those approvals was
for an endoscopy ultrasound which was done on September 28, 2004 -- this was the
crowning victory -- the most definitive test they use for detecting cancer --
and it showed no cancer. This is about the end of the cancer worry -- the
beginning of the celebration of victory over fatal cancer.
Click Here for that report.
Part of the approval
process was a "private-pay" consultation at UCLA, on September 7, 2004 and that
report is HERE. Note the pages you will see
require the use of your "back button" to return to the normal web.
Another success from this
"request" resulted in the approval to have a consultation with the surgeon -- at
UCLA. That gave rise to a detailed letter to the surgeon, outlining the
exact services being requested -- here.
September 9, 2004
Time-Line Of Recent
Consultations
Re: Bonnie J. Troescher
After ending chemo and radiation, entering the Hospice, in June
2004, then starting to get better and considering the choices, I asked the PCP
to request authorization for a PET scan. At that time Bonnie just wanted to
swallow, but if there were any chance of a better prognosis for surgery than we
had had, she want the surgery to “cut the remaining mass” out. We knew from
three CAT scans, at that time that the cancer had not grown for two months prior
to treatment, and had shrunk “at least 30%” during treatment. We also had the
grim prognosis from Dr. Renner that “Bonnie is not a candidate for this surgery,
that the surgery would take some 11 hours, require some 30 days in ICU and give
a 5% chance of survival.” I felt that a PET scan that showed “no cancer” would
allow us to get a different surgeon’s opinion that would be more optimistic.
That PET scan was denied by Lakeside. I complained and Secure Horizons reversed
that denial.
Since Bonnie was not willing to go back to Dr. Renner, or Dr.
Quilixi, for further help on the surgery, the PCP also put in a request for a
“second opinion” from UCLA – since Bonnie’s strongest desire at this time was to
get the surgery if that could be done with a less pessimistic prognosis.
The “second opinion” from UCLA was changed by Lakeside to a
completly unacceptable and non-logical referral to the same oncology clinic
where Dr. Arzoo practices. There would be no way Bonnie would accept any
further advice from that clinic – and we did not feel that this was a proper
referral for a different surgery consultation. This “UCLA second opinion” has
never been handled – Lakeside apparently feeling that the approval of an opinion
from the same oncology clinic was adequate.
Bonnie had the PET scan on August 17, 2004, and it showed no trace
of cancer.
Bonnie continued to feel that the good news from the PET scan
should be presented to a UCLA surgeon and we figured that another necessary step
in convincing a surgeon would be to have another endoscopy. The PCP requested a
consult with a GI doctor, but we had been observing that it seemed to take very
long periods of time to get approvals, then get scheduled for these services and
we did not have much faith that Lakeside would authorize a GI doctor at UCLA.
We made a private-pay appointment with a GI doctor at UCLA for September 7,
2004.
Prior to the time of that appointment the insurance authorization
came through for Dr. Bencharit, GI doctor and we saw him on August 30. We could
have canceled the UCLA appointment, but felt that Dr. Bencharit’s prognosis was
also so grim that we still very much wanted a second opinion from outside the
usual Lakeside doctors. Nonetheless, before seeing the UCLA doctor, we did
accept Dr. Bencharit’s advice that an Upper GI Ultrasound Endoscopy was
appropriate. I felt this would be useful, again, in convincing a surgeon to be
more optimistic about a prognosis for surgery. The request for the EUS was made
by our PCP, but a couple days later, in discussions with the PCP, I began to
think that having the EUS done at UCLA would give us a much better test if the
surgeon were going to be from UCLA. I talked to “Vicki” at Lakeside about
changing the EUS to UCLA – as had once before been ordered by Lakeside.
I then got informal advice that the EUS had been approved,
although the authorization had not been received.
With this background we went to UCLA for the appointment of
September 7th, with Dr. Gareth Dulai. We paid privately for that, at
$210, and specifically now seek retro-active approval and reimbursement, partly
because it became clear to us that the advice we got from Dr. Bencharit was not
medically sound and that we were justified in seeking the original second
opinion from UCLA. Bonnie made it clear to Dr. Bencharit that she would not
accept further chemo or radiation – yet his advice for the ultrasound was
apparently in contemplation that “cancer must exist, not found by the PET, and
that the patient would change her mind about more chemo if faced by the finding
of cancer by EUS.”
Dr. Dulai strongly suggested we have an immediate consult with Dr.
Farrell who does EUS and is far more experienced in placement of stents in the
esophagus that any doctor within the Lakeside group. Dr. Dulai also gave us a
far more optimistic prognosis for the stent treatment than we had previously and
about the service we could get at UCLA.
We saw Dr. Farrell today, September 9th. That too was
a very different view of Bonnie’s prospects than we had had earlier and was
exactly the reason why, I think, second opinions are so routine. We made a
private payment for this consultation of $160. I think this payment should be
retro-actively approved and we be reimbursed for this cost.
His very strong advice was that before Bonnie should make a final
decision on a “stent only treatment” she should have a consultation with the
UCLA specialist in esophageal surgery – again, we understand, far more
experienced in this than anyone we could have ever seen within the Lakeside
group.
We are awaiting a schedule with Dr. Maish, the surgeon, for her
opinions on the options available to Bonnie. If necessary we will again pay
privately on this – but I think that this consult, too, should be approved by
Lakeside, and that we be reimbursed if that approval comes after we have already
paid.
As of this writing I have not yet seen whatever may have been
approved by Lakeside for the EUS. If it comes down as being done by the same
doctor, in the same facility, I would ask for a change to Dr. Farrell at UCLA.
In the meantime Dr. Bencharit’s report from the visit of August 30th
had not been received by the PCP on September 8th, and I see in this
one of those almost deliberate aspects of slowness that reduces the costs of any
health insurance company, but in our case also has meant that without going to
UCLA on a private-pay basis we would still be waiting without any of the
progress we’ve made.
Also, in the meantime, Karen Frye, in Dr. Farrell’s office, said
she would be submitting a direct request for the EUS, assuming that Lakeside
would be willing to change the approval which is apparently “in the works” to
Dr. Farrell.
The final treatments now await the outcome of the consultation
with the surgeon, and Bonnie’s considerations, but the treatment could be:
o
Stent put in by Dr. Farrell
o
Or
o
Surgery by Dr. Maish.
o
Possibly both
I do not ask, now, that Lakeside give some “pre-approval” to
either of these procedures, but do want Lakeside to know what seems to be
medically appropriate.
Reports from Dr. Dulai and Dr. Farrell, plus one upcoming from
Dr. Maish, will be placed into the system at UCLA, and sent to our PCP promptly.
Bonnie has yet to hear more about the surgery before she
makes a decision on whether to accept that. Under no circumstances will Bonnie
accept more chemo or radiation. It that means that either of these two
procedures must be accepted as “palliative” that is fine with Bonnie.
Sincerely,
Karl Loren
This
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of fresh air in a world of pollution.
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