Blue Cross denies coverage

We are being told constantly by those that oppose healthcare reform that the government will interfere between patient and doctor. I have stated that for years the Insurance companies are already doing that. Frankly at least I know the government won't do it for profit motives - unlike for-profit companies!

Blue Shield of CA refuses to treat cancer patient

by MrBurns17

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Tue Aug 04, 2009 at 05:12:25 AM PDT

A woman and her doctor discuss cancer treatment options.

They decide on Treatment "A"

Then the insurance company decides to chime in

The sanctity of the doctor - patient relationship is then flushed down a Conservative-funded toilet.

This horror story involves a Chico, CA woman, Shelly Andrews Buta, whose insurance company won't pay for the cancer treatment that, at least for now, has saved her life.

Shelly is a former Girl Scout troop leader, and a single parent who's raising two high school students.

Shelly fought breast cancer and had been cancer-free nearly five years when, in April of 2009, she started feeling something like paralysis in the left side of her body. Medical tests showed the cancer had returned. It was on her back, one lung and, most alarming, in her brain.

The 14 tumors in her brain needed immediate attention. Specialists at UC San Francisco Medical Center recommended a procedure called gamma knife radiation, where the lesions are zapped with gamma rays and without knives.

Her doctors said without the surgery, she would die. But on the day of the procedure, her insurance carrier, Blue Shield, said it wouldn't pay the $60,000 tab.

Blue Shield of California decided that treating Shelly Andrews-Buta was just too expensive. So they overruled her doctor's decision, and denied treatment. They "recommended" a cheaper (and much riskier / less effective) alternative.

Blue Shield said it would pay instead for a less expensive treatment called whole-brain radiation, in which doctors try to kill tumors by exposing the entire brain to radiation. But Dr. Sneed said that wasn't the best option for Andrews-Buta.

"Gamma knife treatment works faster than whole-brain radiation in shrinking lesions," Sneed said. She believes Andrews-Buta's tumors are growing too quickly to be halted by the whole brain radiation.

Sneed is considered an expert on both procedures but said Blue Shield representatives didn't seem to want to listen to her opinion.

"There wasn't enough opportunity, I believe, to discuss it and talk about the pros and cons, and my rationale," she said.

So why did Blue Shield overrule Dr. Sneed? In emails, a company representative told CBS 5 Investigates that Blue Shield's position is that for patients with multiple tumors, gamma knife surgery 'does not improve survival' better than whole brain radiation.

At this point, if (when) this woman dies, there is no legal recourse. Private insurers cannot be held accountable for causing the death of a subscriber, even when they deliberately deny to cover physician prescribed treatment! This is the little known ERISA preemption rule, that bars patients from suing health insurers (when the benefit is provided through an employer). Of course, even if you buy your own junk policy (because that's all that's available in the "free" market), you'll be limited in your recourse with mandatory arbitration clauses and the like.

Shelly Buta, (a paying subscriber), had to take up a collection to pay for a round of chemotherapy. The cost was staggering; $30,000... she still owes on this balance but at least she received some treatment. Of course this is only one round of chemo.

And she's not the only cancer patient who will be forced to go without care, and maybe die early so another claim manager can get their annual bonus....

It would be advisable for Conservatives to read this tragic story (as well as others like Natalie Sarkisian's), and think long and hard before they disrupt another town hall meeting, or start spewing their usual venom about "government health care ... secret plans to kill seniors", etc, etc. These hateful miscreants need to be reminded that medical decisions in today's system are not made between the patient and their doctor; it's always the bean counter at the corporate office who decides who lives and who dies. Milton Friedman would be so proud.

Comic Relief: Blue Shield Boilerplate Response:

"Blue Shield makes medical necessity decisions based on what is the most appropriate safe and effective treatment. To do that, we rely on the best evidence-based medical research available and the clinical opinion of medical experts. While we approve of gamma knife surgery when appropriate, in this case, the most appropriate treatment is whole brain radiation therapy, which we would approve for medical necessity if requested."