Bob I think you said March 7th

I can't stand bureaucrats in the process period... and in between a dr and determining medical necessity even less.

And anyone that thinks handing these decisions over completely to the govt will improve things is a fricking idiot.

See: va, dmv, irs, mic, post offices... etc.

Right click "Save image as"  might work..

PkrBum wrote:I can't stand bureaucrats in the process period... and in between a dr and determining medical necessity even less.

And anyone that thinks handing these decisions over completely to the govt will improve things is a fricking idiot.

See: va, dmv, irs, mic, post offices... etc.

I know what you mean, this is just bullshit. I did notice the date of the letter was March 4th, 3 days before the procedure. Surely the doctor or his staff would have known and fought it. Bob, was told it was pre-approved by the Doctor.

But all in all one of our office staff will help him appeal and probably have to get doctor's documentation why it had to be completed in the manner.

This is how gd f'up insurance company's are, if Bob would have had his chest opened it would have required a 3 or more days stay and the insurance company would be on the hook for that much more.

Every bureucrat are looking for a way out not to pay.

Hallmarkgard wrote:Right click "Save image as"  might work..

Thanks, didn't think of that, it worked.

Bob, you had that laid out on a grate, were you planning on burning it?

I am really confused. I thought you had lung surgery, but it appears you just had what I had four weeks ago with a bronchoscopy surgery to debulk my four marble sized tumors. They did NOT use a robot to do my surgery at Northwestern and it really is a routine procedure which I had argued they should have done to take the biopsy where all they do is go down your breathing tubes and cut, without opening the body with an incision. In your case it appears they went down the bronc and removed the tumor and some area around the tumor with the robot. In my second bronc a month ago they went down and cut away as much of the tumors as they could until the vascular structure started bleeding and they cautuorized each tumor and radiate them, but again no robot, and other than coughing up blood for a week not much pain except my tongue where either the freezing agent, heat, or radiation caused burning on the surface of the tongue. I completely understand why the insurance company is raising hell. It is a bronc. I have NEVER been offered a robot to do a bronc, now if they cut through your body to get to the lung, which I thought the robot was going to do with a much smaller incision, but the letter says you had a bronc which is a routine method for taking biopsies or removing small tumors or in my case debulking. My first bronc, I was not even completely out when the doctor showed me my tumor, took some tissue for biopsy, and other than a chipped tooth, it really was less intrusive than a colonoscopy.

Help my Bob, did they cut through your body with the robot to get to the lung, or did they go down your throat. If they went down your throat and the doctor is saying they had to use a robot......the insurance folks are going to have a chit fit, because I have never heard of the same, and I am going to a top ten facility in America, and have always had my broncs paid for completely without question. The experimental part they are discussing is that the extra cost of the robot will not be paid unless the doctor has proof that this results in better results with hard stats and not just his preference or experiment, and I do not think it is question of the need for the procedure, rather the way this entire thing was sold to you, and now the insurance company is not buying it.....it never made sense to me from the get go.....it is a simple bronch.

When you see the word "bronch" being used here,  seaoat,  it's describing something completely different.
I now have three holes in my left side.  Those are what the robot used.

Bob wrote:When you see the word "bronch" being used here,  seaoat,  it's describing something completely different.
I now have three holes in my left side.  Those are what the robot used.

I was just reading oats response and was going to reply. You beat me to it. But he has also given me another thought, who ever does the coding did it wrong.

"bronchoscopy with computer assisted image guided navigation"

That's the official medical name of the procedure which was not approved.

Are you thinking the name of the procedure is wrong,  ppaca?

This is part of the paperwork I was given in a pre-op appointment.
As you can see it lists my procedures this way...


"Navigational Bronchoscopy,  Left Upper Lobe,  Dye Injection,  Left Da Vinci Robotic Exploration, Left Upper Lobe Wedge,  Mediastinal Lymph Node Sampling,  Possible Thoracotomy"

when I google does Medicare pay for your exact wording this is what comes up:

LCD for Electromagnetic Navigation for Bronchoscopy (L30171)


Contractor Information


Contractor Name
National Government Services, Inc.
Contractor Number
Number Type State(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B

Carrier
Fiscal Intermediary
MAC – Part A
MAC- Part B


LCD Information


LCD ID Number
L30171

LCD Title
Electromagnetic Navigation for Bronchoscopy

Contractor's Determination Number
L30171 (R2)

AMA CPT / ADA CDT Copyright Statement
CPT codes, descriptions and other data only are copyright 2009 American Medical Association (or such other date of publication of CPT). All Rights Reserved. Applicable FARS/DFARS Clauses Apply. Current Dental Terminology, (CDT) (including procedure codes, nomenclature, descriptors and other data contained therein) is copyright by the American Dental Association. © 2002, 2004 American Dental Association. All rights reserved. Applicable FARS/DFARS apply.

CMS National Coverage Policy
Language quoted from Centers for Medicare and Medicaid Services (CMS). National Coverage Determinations (NCDs) and coverage provisions in interpretive manuals is italicized throughout the policy. NCDs and coverage provisions in interpretive manuals are not subject to the Local Coverage Determination (LCD) Review Process (42 CFR 405.860[b] and 42 CFR 426 [Subpart D]). In addition, an administrative law judge may not review an NCD. See Section 1869(f)(1)(A)(i) of the Social Security Act.

Unless otherwise specified, italicized text represents quotation from one or more of the following CMS sources:

Title XVIII of the Social Security Act (SSA):

Section 1862(a)(1)(A) excludes expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

Section 1833(e) prohibits Medicare payment for any claim which lacks the necessary information to process the claim.

Primary Geographic Jurisdiction
Number Type State(s)
00130 FI IN
00131 FI IL
00160 FI KY
00332 FI OH
00450 FI WI
00452 FI MI
00453 FI VA, WV
00630 Carrier IN
00660 Carrier KY
13101 MAC CT – Part A
13102 MAC CT – Part B
13201 MAC NY – Part A
13202 MAC NY – Part B
13282 MAC NY – Part B
13292 MAC NY – Part B

Read this careful

Indications and Limitations of Coverage and/or Medical Necessity
Abstract:

Electromagnetic Navigation Bronchoscopy (ENB) is a new method to increase diagnostic yield of small peripheral and mediastinal lung lesions in patients where standard techniques were nondiagnostic. This local coverage determination (LCD) specifies the indications and limitations for this new technology. ENB is indicated for patients identified with a solitary pulmonary nodule, for patients with an identified lung lesion(s) and a coexisting cancer and for patients who are being considered for radiotherapeutic treatment of a thoracic neoplasm.

Indications:

Despite medical advances in the last 50 years, lung cancer causes more deaths than any other cancer in both men and women. It is now the most common form of cancer diagnosed in the United States and a major cause of death, accounting for 14% of all cancers and 31% of all cancer deaths in males.

The ENB system uses a sensor probe that picks up the electromagnetic field generated by a localization system (a processor, amplifier and a location board). When the sensor is placed within the electromagnetic field, its position and orientation can be identified and this information is displayed on a monitor and superimposed upon previously acquired computed tomographic (CT) images. This image-guided localization device is designed to aid in guiding transbronchial biopsies in desired predetermined targets within the bronchial tree.

The ENB system consists of four essential components:

computer software that creates a three-dimensional (3D), virtual bronchoscopy reconstruction from CT images;
an electromagnetic location board that emits a low-dose electromagnetic field;
a sensor probe that has an 8-way steering mechanism and is locatable within the electromagnetic field, and
an extended working channel (EWC) that when secured enables the placement of the bronchoscopic tools to the lung periphery.
The digitized information from the patient’s CT scan is imported into the ENB system where axial, coronal and sagittal views of the chest and virtual endoscopy images are reconstructed. Anatomic landmarks are identified as coordinates on the corresponding CT and on the virtual bronchoscopy image (planning). The same identifiable landmarks are then used during real-time bronchoscopy to relate the CT data to the actual anatomy. When these points are touched with the sensor, they are simultaneously recorded by the navigation system (registration). After registration, navigation is performed with simultaneous advancement of the steerable probe to the lesion.

Finish reading here:

https://apps.ngsmedicare.com/lcd/LCD_L30171.htm

If Medicare would pay then medicare advantage pays.



I am thinking the doc needs to explain why he did it that way and refer to the authorization he received and told you about before procedure.

Yes you will appeal and the person I told you about in our customer service can help. If your appt with chomiak is Tuesday I'd certainly bring this up.

ppaca wrote:

I am thinking the doc needs to explain why he did it that way and refer to the authorization he received and told you about before procedure.

Yes you will appeal and the person I told you about in our customer service can help. If your appt with chomiak is Tuesday I'd certainly bring this up.

I'll definitely bring it up with him.  But I was hoping to spend as much time as I could getting him to explain the pathology report.  These physicians working within the world of corporate medicine give you about 5 minutes tops.

If I was to ultimately lose on this,  I feel certain it would lead to medical bankruptcy. 
And then I'm wondering if Sacred Heart would try to refuse me further treatment when there is the risk that I can't pay for it.

I am more lost than I was before. Your tumor was in your upper left lobe. My first tumor was in the same place. They went down with a bronc and took pictures and took tissue. I was awake during most of the procedure and they showed me the tumor on the screen. The pathology indicated an atypical carcinoid NET tumor, and they then came in under my armpit and removed most of the upper left lobe and some Bronchial tube.

The second bronc, they put me out completely and made the distinction between the first being a flexible bronc, and the second being a rigid bronc. There were no holes in my chest or under my arm and they took the tumor material out the bronchial tube and through my mouth. Now my question is were they removing material through your chest or under your arm through the holes they put in you, or were they probes for the robot to locate the tumor. I am learning a great deal, and have never had any pulmonary doc tell me about a robot procedure on a bronc. My first pulmonary doc was a teacher at a big ten medical school, but had not dealt with NET tumors, and the second Pulmonary Doc was at Northwestern and had done a 150 procedures on NET tumors. My question was did they remove parts of your lung through the holes.....was it for tools to do the procedure, or were they probes to locate and get a better view of what they were doing. I mean this is great technology if they can successfully remove a tumor in the left lobe and not have to resection the entire lob. More breathing capacity, less recovery time, and much less pain......I am so confused. I hope you can ask the doc questions as to what they did to you...I learn something new on this forum every day. I cannot see you paying one dime for this procedure. The tumor was there. The doc removed it. If they say that he should only get paid the regular bronc charge.....the doctor is going to have to eat the difference. You should not have to pay the difference. I hope it was a coding error, but I am beginning to understand why I was uncomfortable with what this guy was saying from the git go.....he is either on the cutting edge of lung surgery, or he is not that good and needs the machine to make his work good.....I tend to think he is on the cutting edge if he got it all, and all they put in you were probes....pretty cool. Now some good news on the biopsy.......histoplasmosis from all that picking where molds and fungus were.......fingers crossed it is not small cell.

Yes,  the Da Vinci robot (with the surgeon controlling it) was able to perform a wedge resection,  seaoat.

Three small incisions were made in my left side.  One was for insertion of the robot's camera.  This thing has a HiDef 3D camera with 10x magnification.
The other two incisions are for the operating arms on the robot.  And yes one of those has a receptacle on the end.  And the other arm deposits the lung tissue into that receptacle for removal.  Obviously it takes more than one insertion because the receptacle is very small and can hold only a limited amount of tissue.  That was probably a big contributor to the operation taking 3 and a half hours.

I just read over your last few posts and I think I know what's confusing you.  It's you seeing that word "bronc" and assuming it's referring to what you think it is when it is not.  Apparently there are many different procedures which can be associated with the word "bronchoscopy".

Just thought of something.  Blue Cross is not just arguing with my surgeon on  this.  Because remember I got a 2nd opinion from an oncologist at MD Anderson and he agreed with everything the surgeon had proposed to do.
So Blue Cross is disputing him too.  lol

ppaca wrote:

Bob wrote:When you see the word "bronch" being used here,  seaoat,  it's describing something completely different.
I now have three holes in my left side.  Those are what the robot used.

I was just reading oats response and was going to reply. You beat me to it. But he has also given me another thought, who ever does the coding did it wrong.

I think you said that right off, ppaca, that it could be a coding error.  I hope you're right and it sure seems feasible.

Bob wrote:If I was to ultimately lose on this,  I feel certain it would lead to medical bankruptcy. 
And then I'm wondering if Sacred Heart would try to refuse me further treatment when there is the risk that I can't pay for it.

Bob I can totally relate to your fears here, and I know it's easy for me to say, but I do hope you will try as hard as you can to spare your system the stress of worrying about this right now.  I have to believe that between you and ppaca and the docs' offices this WILL be cleared up, and hopefully in very short order.   In the first place it's difficult to contemplate that an advance auth wasn't obtained.  And yes, that's not a guarantee of payment, but it should be pretty close to same IF the procedure was coded the same as the auth request.  

I'm hoping for a simple clerical error, and am SO glad you have ppaca to advise you.

You will not pay a dime for this procedure. It was either a coding error, or the doc is going to eat it. Informed consent involves communicating the risk that medicare or your supplementary insurance may not cover the procedure. I had a cat scan which was rejected.......appealed and they paid. It is not enough that you have to worry about your illness, but the bastards make this whole thing too complicated. Real health reform requires streamlining the billing process. However, in my case, my second 30mg shot of sandostatin will not be paid by medicare and I will suffer at the end in December if I make it that long. We will be meeting with my wife's teacher retirement medical folks to see if we can stay on the plan and continue the premiums rather than going on medicare....we will also see if a supplemental policy will cover the second shot. They claim the second shot is experimental and not enough data to prove it is effective.......The data is overwhelming that the efficacy of the second shot relieves symptoms of the cancer patients, and that for four years the data is clear.....but they still are denying coverage, and it is no fun in the waiting room when some people who need the second shot are being denied because they are now on medicare. It is very sad. People are suffering and they either come up with an extra 3,400 bucks a month or their tumors grow and the end comes faster.....some of the most uncomfortable conversations in my life have been on the 21st floor discussing how unfair our medical system has become.

I have little doubt this will be covered, or the doc is going to eat part of his charges......I now understand that this procedure saved money in both hospital time and complications. Medicare got a bargain if this guy pulled this off, and how stupid would it be if a procedure saves the government money, so they refuse to pay the same, and a patient can suffer horrible pain and spend more government dollars.....and they will accept that course......stupid.....bone chilling stupid.

2seaoat wrote:I now understand that this procedure saved money in both hospital time and complications.   Medicare got a bargain if this guy pulled this off, and how stupid would it be if a procedure saves the government money, so they refuse to pay the same, and a patient can suffer horrible pain and spend more government dollars.....and they will accept that course......stupid.....bone chilling stupid.

I could not agree more with every word of that.  It is the ultimate irony.

BUT,  this time it's not Medicare at fault.  This time it's the insurance company.

I'm on Medicare Advantage.  Advantage completely replaces Medicare.  Once I opt for Advantage,  the insurance company has to absorb all the bills over and above my premiums and copays,  not Medicare or the government.

This will not even go to appeal. The doctor's office will get this done. You will not pay a dime. We have gotten the letters of non coverage....you become numb, but in this case it is stupid.......all they are doing is creating unnecessary stress for you, again I am a firm believer that I would rather get bad news in billing which can be corrected than bad news in pathology...so under my theory you will be getting good news on Tuesday.........

ppaca wrote:

Bob wrote:When you see the word "bronch" being used here,  seaoat,  it's describing something completely different.
I now have three holes in my left side.  Those are what the robot used.

I was just reading oats response and was going to reply. You beat me to it. But he has also given me another thought, who ever does the coding did it wrong.

That's usually the problem....it is so much bullshit associated with billing and coding. The rules change all the time. Medicare gives updates and changes almost every month.

An entry level billing clerk can screw everything up without even knowing it or should I say not knowing what she is doing. Medical personnel have been replaced with coders and billing personnel....and it is getting worse.

2seaoat wrote:This will not even go to appeal.  The doctor's office will get this done.  You will not pay a dime.  We have gotten the letters of non coverage....you become numb, but in this case it is stupid.......all they are doing is creating unnecessary stress for you, again I am a firm believer that I would rather get bad news in billing which can be corrected than bad news in pathology...so under my theory you will be getting good news on Tuesday.........

Seaoat is probably right; this may not even require a formal appeal.   Sea, I like your theory about the pathology, too -- may it be so!! That would be a real Super Tuesday for Bob!!!!