Sunday, January 6, 2008

Criminal Behavior

I am in a catch 22 here- I want to name the perpetrator of the criminal behavior, but if I do, then they can do more damage to me, if that is even possible. Forgive me for being vague- trust me I want to scream their name from the highest rooftop.

I have had the same insurance carrier since 1992. First it was a group plan, then it went to a private plan. Then I got cancer and I now I am stuck with them forever-and I am at their mercy. Mercy is not something that they have a lot of.

I have been denied many things over the years. MRIs, PT scans, etc. But they eventually get approved after many letters and phone calls and hounding.

When I was diagnosed for a second time last February, they approved my surgery and they approved my plastic surgeon because he is the only person in the area who is able to reconstruct previously radiated skin. The surgeries went well. I started chemo and had a few skirmishes with them approving certain drugs, but they relented.

Then one of the tissue expanders ruptured. This is not a life threatening event. However, it is threatening to the future of the final product of reconstruction. If a new one was not put in place, I would lose the pocket created and thus not be able to get the final implant.

The first letter came stating I did not need a new expander.

The second letter came stating that they are no longer covering me for plastic surgery.

These were responded to- and the Federal LAW that was passed that forces insurance companies to pay for reconstruction after breast cancer was quoted.

The third letter came that stated they will not permit my plastic surgeon to be my doctor- ever again.

This doctor- the only one in the area who can do the complicated and intricate work that my previously radiated skin calls for- is no longer allowed to treat me.
We countered with their original APPROVAL of him.

They returned serve and said that they made an error... and I should stop abusing the system.

We got the ACS involved and the NY State Attorney General's office. At the eleventh hour, while waiting in the OR in the only time slot that I could get the surgery between chemo breaks, the "conditional approval" came through for a one time exception for this ONE procedure and that in the future I was not to "attempt to get around" the system again.

They feel that a local plastic surgeon who specializes in children's cleft palate deformities can be the one to finish the intricate work that my plastic surgeon pioneered. I met with this new doctor. She is lovely. She also thinks they are out of their minds and refused to complete my reconstruction.

Time passes and I had chemo to complete so we have put the fight for my implant exchange on a shelf until we need to haul it out again.

Chemo is over. Now is the time for radiotherapy. I had four positive lymph nodes with cancer that went outside the lymph nodes. This means it could have spread to the subclavicle nodes, the mediastinal node as well as the chest wall. I have no option. I need radiation and a lot of it.

I was mapped for it and tattooed. They even had to deflate an expander to get a better shot at the tumor field. I am scheduled to begin tomorrow morning.

I received a letter in the mail yesterday from my insurance company. Their medical director has decided that I do not need radiation. He says it is "not medically necessary" he also says that "radiation has not been proven in the treatment of breast cancer"

I would like to know who this person is.
I want to go to his house.
I want to see how he lives and look him in the eye.
I want to meet his kids.
I want to know what kind of a man decides the fate of people's lives.
Then I want to talk to him about his medical credentials. I will show him the thousands of studies on the benefits of radiotherapy. I want to ask his wife when she had her last mammogram. I want to know how his mother is feeling. I want this man to see the face of one of the thousands of people he so cavalierly dismisses and declares not medically necessary.

I am not going to just fight for radiation tomorrow.
I am going to fight to have this man removed from his position.
What he has done is criminal.
And I am not just referring to myself. I know of other women who he has decided that they do not need Avastin for their mets. Who he feels a diagnostic breast MRI is not necessary in a breast cancer patient with dense breast and a history of DCIS and ALH. I also know he denied my friend Tom the proper treatment for his lung cancer and he died while waiting for his appeal to come through.
I want this man to pay for what he is doing to those of us who are too sick and too tired and too worn out to fight.

I don't only want my radiation to start tomorrow.
I want this man- the medical director of my insurance company- to pay.

4 comments:

Ferne said...

You go girl. It ain't right.

kathy said...

NO SURRENDER!!!!!

(nice hint;) )

kath

Elmer said...

You are so brilliant!

Carrie

Jenster said...

I am so angry right now. You're right. It is CRIMINAL and there is no excuse. None!