Blue Shield Won't Pay NorCal Mom's Cancer Treatment

[jpeyton]

Text

Will your insurance company pay for the treatment your doctors recommend? They may not. That's what a single mother from Chico said she found out.

In late April, Shelly Andrews-Buta was scheduled to undergo treatment for breast cancer that had spread to her brain, threatening her life.

The experience has been emotionally devastating. "I have two beautiful children, you know, I'm a single mom, they need me to be around," Andrews-Buta told CBS 5 Investigates.

But instead of having doctors working to remove her brain tumors on the day the surgery was scheduled, she sat in a San Francisco hotel room. Why? Because at the last minute, her insurance company, Blue Shield, decided it wasn't going to pay for the treatment her doctors at UCSF Medical Center had recommended.

Andrews-Buta was stunned. "I mean this is my life, this is my life, this isn't, gee, if we don't do it you're just going to have a cut that doesn't heal, this is you're going to die," she said.

Without treatment, her doctor told her she in fact would die: tumors had invaded 15 separate areas in her brain.

"I wanted to rapidly get control of these lesions," said UCSF radiation oncologist Dr. Penny Sneed. "I felt there was a great time urgency, and we couldn't wait."

Just two weeks prior to the scheduled date for surgery, Andrews-Buta could still walk. Now she's almost paralyzed and unable to walk without assistance.

Dr. Sneed told her that her best chance of survival lay with a high-tech machine called a "gamma knife."

There's no actual cutting with the knife. Instead, the beams of radiation called gamma rays target a tumor from multiple angles.

The radiation can shrink and even kill a tumor without harming surrounding brain tissue.

Dr. Sneed, who is co-director of UCSF's Gamma Knife Radiosurgery Program, described it as an amazing machine and the most appropriate treatment for Andrews-Buta.

But the doctor said when it came to getting Blue Shield's approval for the procedure; she was surprised to learn that the company's policy lays out that a patient who has more than three brain tumors, what doctors call lesions, would not be covered for the gamma knife procedure.

Dr. Sneed felt the policy was unreasonable. "What I was up against was just a rule: 'Well, if it's more than three lesions, that's too many,'" Sneed said.

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.

But UCSF doctors say whole brain radiation has serious side effects as well.

"When the whole brain is irradiated, it suffers some form of injury," according to UCSF neurosurgeon Michael McDermott, also a co-director of the gamma knife program.

"What we're looking at is permanent or irreversible changes in the brain", said McDermott.

And Dr. Sneed said many patients suffer the effects of the radiation in their everyday lives. "They may have trouble remembering things. And that can really impact their quality of life, ability to work and function."

Other insurance companies do cover the procedure. Just a week after Andrews-Buta's treatment was denied by Blue Shield, a patient with similar cancers had her gamma knife treatment approved by a different insurance company.

Courtney LeBoeuf also suffers from breast cancer that metastasized to the brain and she, too, has multiple tumors exceeding Blue Shield's guidelines; in her case there are 10 tumors in her brain.

"I've heard wonderful things about this procedure," said LeBoeuf shortly before undergoing treatment. "And many women and men who have gone before me have had tremendous results with very little side effects."

They're results Shelly Andrews-Buta wanted her to be able to get as well. So a group of her friends got together and raised more than $30,000 to put toward paying for her treatment. Andrews-Buta still owes about $12,000 but her friends will hold a fundraiser at the end of June to cover the remainder of the cost.

Blue Shield sent the following statement to CBS 5 Investigates regarding Shelly Andrews-Buta's case:

"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."

Who needs a government bureaucrat between you and your doctor when an insurance claims adjuster is so much better? Apparently these claims adjusters know more about cancer treatment than world-renowned oncologists.

 

[theeedude]

That's free market medicine for ya.

 

[Patranus]

And what will single payer change about this?

Can't even get cortisone shots in England for back pain.

EDIT:
If you actually read the article there is NOTHING that says the "gamma knife" procedure is better than hole brain radiation. While it might have more side effects, the according to the article the effectiveness is roughly the same

So, it is perfectly logical that the cheaper alternative would be used if the RESULTS are the same in terms of treatment.

 

[Fear No Evil]

Perhaps you should put your money where your mouth is and donate to her cause?

 

[TruePaige]

Originally posted by: Fear No Evil
Perhaps you should put your money where your mouth is and donate to her cause?

If only there was some single entity that could put money forth to take care of dying people..

Oh right, the government.

 

[Hayabusa Rider]

Originally posted by: TruePaige

Originally posted by: Fear No Evil
Perhaps you should put your money where your mouth is and donate to her cause?

If only there was some single entity that could put money forth to take care of dying people..

Oh right, the government.

Why do you think the government would do any differently? The OP has in the past defended the government if they decided that someone was too far gone. He even suggested that the solution would be for the patient to buy private health coverage. So someone has 15 brain tumors and while it's OK if the government tosses her to the wolves, it's a crime when the insurance says no.

A complete disconnect.

 

[fallout man]

Originally posted by: Patranus
And what will single payer change about this?

Can't even get cortisone shots in England for back pain.

EDIT:
If you actually read the article there is NOTHING that says the "gamma knife" procedure is better than hole brain radiation. While it might have more side effects, the according to the article the effectiveness is roughly the same

So, it is perfectly logical that the cheaper alternative would be used if the RESULTS are the same in terms of treatment.

A gamma knife is able to focus high levels of radiation with high precision. This way, you concentrate the deadly radiation mostly where the tumor(s) are. To get the same effect with whole brain irradiation, you'd have to use a very large amount of radiation over the entire head.

The results are not the same, because the therapeutic dose required to kill off the tumors with a GK is limited to a fraction of the tissue in the head. Irradiating the whole head with such high doses is bad.

Gamma-knives are cool.

Edit: I.E. It's not like comparing foot fungus cream at CVS.

 

[theeedude]

Wow, that high tech treatment that she won't be getting is the best in the world. Great stuff. Not for her, but in general.

 

[Hayabusa Rider]

Originally posted by: senseamp
Wow, that high tech treatment that she won't be getting is the best in the world. Great stuff. Not for her, but in general.

So would it be any better if UHC didn't get her the best in the world either?

Oh snap, of course they would. UHC will take care of everything, and if it doesn't then the lie will have been worth it.

 

[fallout man]

Originally posted by: Hayabusa Rider

Originally posted by: senseamp
Wow, that high tech treatment that she won't be getting is the best in the world. Great stuff. Not for her, but in general.

So would it be any better if UHC didn't get her the best in the world either?

Oh snap, of course they would. UHC will take care of everything, and if it doesn't then the lie will have been worth it.

What makes you think that UHC would deny her treatment? The government can just print/borrow more money to pay for her treatment.

They certainly did it to kill thousands, so why not do it to save thousands?

 

[theeedude]

Originally posted by: Hayabusa Rider

Originally posted by: senseamp
Wow, that high tech treatment that she won't be getting is the best in the world. Great stuff. Not for her, but in general.

So would it be any better if UHC didn't get her the best in the world either?

Oh snap, of course they would. UHC will take care of everything, and if it doesn't then the lie will have been worth it.

Well, if it doesn't she'd be no worse off than she is now.

 

[Hayabusa Rider]

Originally posted by: fallout man

Originally posted by: Hayabusa Rider

Originally posted by: senseamp
Wow, that high tech treatment that she won't be getting is the best in the world. Great stuff. Not for her, but in general.

So would it be any better if UHC didn't get her the best in the world either?

Oh snap, of course they would. UHC will take care of everything, and if it doesn't then the lie will have been worth it.

What makes you think that UHC would deny her treatment? The government can just print/borrow more money to pay for her treatment.

They certainly did it to kill thousands, so why not do it to save thousands?

That's an interesting idea. Let's extend that and just get rid of taxes completely. They print money to pay for health care, wars, whatever. Carte blanc!

 

[Budmantom]

Originally posted by: jpeyton

Who needs a government bureaucrat between you and your doctor when an insurance claims adjuster is so much better? Apparently these claims adjusters know more about cancer treatment than world-renowned oncologists.[/quote]


Are they depriving her of those pain killers that treat cancer?

 

[bamacre]

Anyone who thinks what we have now is "free market" health care is a loon. Or just completely ignorant.

 

[MikeMike]

hey wait, you know the fun thing about a "free market", there are things called COMPETITORS, as in YOU HAVE A CHOICE...

from the article

Other insurance companies do cover the procedure. Just a week after Andrews-Buta's treatment was denied by Blue Shield, a patient with similar cancers had her gamma knife treatment approved by a different insurance company.

nope, no slant at all in your bullshit.

 

[theeedude]

Originally posted by: bamacre
Anyone who thinks what we have now is "free market" health care is a loon. Or just completely ignorant.

Wait, the government forced BCBS to deny her care? Or maybe it was a free market decision to do what's best for their shareholders?

 

[Kadarin]

But with government healthcare, we'd have a bureaucrat between her and her doctor...

 

[bctbct]

While I sympathize with this woman it sounds like the final outcome is going to be the same either way.

IMO there is a point where throwing money at something becomes a burden on people who pay insurance rates.

 

[Hayabusa Rider]

Originally posted by: senseamp

Originally posted by: Hayabusa Rider

Originally posted by: senseamp
Wow, that high tech treatment that she won't be getting is the best in the world. Great stuff. Not for her, but in general.

So would it be any better if UHC didn't get her the best in the world either?

Oh snap, of course they would. UHC will take care of everything, and if it doesn't then the lie will have been worth it.

Well, if it doesn't she'd be no worse off than she is now.

And so UHC isn't any better for her, but we can extend to everyone the right to be denied. That's the beauty of it. While some might be covered before, everyone gets that privilege.

Sorry, but until someone comes up with more than obfuscation I'm not supporting it. I'm not taking the word of people content to lie or misrepresent UHC, and I'm referring to Congress and Obama.

 

[Hayabusa Rider]

Originally posted by: bctbct
While I sympathize with this woman it sounds like the final outcome is going to be the same either way.

IMO there is a point where throwing money at something becomes a burden on people who pay insurance rates.

You've got to get with the program. If the government were to do this it would be prudent conservation of scarce resources. If an insurance company does it, then it's evil for profit avarice.

It's not what's done but who does it that matters most, or so it seems.

 

[theeedude]

Originally posted by: MIKEMIKE
hey wait, you know the fun thing about a "free market", there are things called COMPETITORS, as in YOU HAVE A CHOICE...

from the article

Other insurance companies do cover the procedure. Just a week after Andrews-Buta's treatment was denied by Blue Shield, a patient with similar cancers had her gamma knife treatment approved by a different insurance company.

nope, no slant at all in your bullshit.

Yeah, that helps her a lot. If only she knew to ask if gamma-knife treatment was covered before she got cancer and found out what gamma-knife treatment was. Or maybe if her employer did before signing her up for this plan.

 

[Hayabusa Rider]

Originally posted by: senseamp

Originally posted by: MIKEMIKE
hey wait, you know the fun thing about a "free market", there are things called COMPETITORS, as in YOU HAVE A CHOICE...

from the article

Other insurance companies do cover the procedure. Just a week after Andrews-Buta's treatment was denied by Blue Shield, a patient with similar cancers had her gamma knife treatment approved by a different insurance company.

nope, no slant at all in your bullshit.

Yeah, that helps her a lot. If only she knew to ask if gamma-knife treatment was covered before she got cancer and found out what gamma-knife treatment was. Or maybe if her employer did before signing her up for this plan.

Well, if UHC doesn't cover it she'd be no worse off than she is now.

 

[theeedude]

Originally posted by: Hayabusa Rider

Originally posted by: senseamp

Originally posted by: Hayabusa Rider

Originally posted by: senseamp
Wow, that high tech treatment that she won't be getting is the best in the world. Great stuff. Not for her, but in general.

So would it be any better if UHC didn't get her the best in the world either?

Oh snap, of course they would. UHC will take care of everything, and if it doesn't then the lie will have been worth it.

Well, if it doesn't she'd be no worse off than she is now.

And so UHC isn't any better for her, but we can extend to everyone the right to be denied. That's the beauty of it. While some might be covered before, everyone gets that privilege.

Sorry, but until someone comes up with more than obfuscation I'm not supporting it. I'm not taking the word of people content to lie or misrepresent UHC, and I'm referring to Congress and Obama.

Everyone already has the right to be denied, so UHC would not extend it to anyone. You can have your blinders on, noone is stopping you.

 

[MikeMike]

Originally posted by: Hayabusa Rider

Originally posted by: bctbct
While I sympathize with this woman it sounds like the final outcome is going to be the same either way.

IMO there is a point where throwing money at something becomes a burden on people who pay insurance rates.

You've got to get with the program. If the government were to do this it would be prudent conservation of scarce resources. If an insurance company does it, then it's evil for profit avarice.

It's not what's done but who does it that matters most, or so it seems.

I am afraid however of all the people who will expect that to not be true, those that think, you know, i have healthcare and terminal cancer... i want to TRY to live and force them to keep me alive, than to accept the doctor, and other doctor, and other doctor, have said...

the system will be full all the time
the limits will be crazy low.

 

[fallout man]

Originally posted by: Hayabusa Rider

Originally posted by: fallout man

Originally posted by: Hayabusa Rider

Originally posted by: senseamp
Wow, that high tech treatment that she won't be getting is the best in the world. Great stuff. Not for her, but in general.

So would it be any better if UHC didn't get her the best in the world either?

Oh snap, of course they would. UHC will take care of everything, and if it doesn't then the lie will have been worth it.

What makes you think that UHC would deny her treatment? The government can just print/borrow more money to pay for her treatment.

They certainly did it to kill thousands, so why not do it to save thousands?

That's an interesting idea. Let's extend that and just get rid of taxes completely. They print money to pay for health care, wars, whatever. Carte blanc!

You're being facetious.

Don't you think that the buying power of the government to get contracts for bombs and grenades would be just as effective in the realm of healthcare?

If my government can afford to get into a huge debt to wage war--literally blowing up money, it should definitely be able to afford to sustain a health insurance program which other Americans and I would be paying into, just like any other current insurance program. Those programs make a profit, and they have limited power to negotiate. The unfortunate part is that they make their profit not through negotiation, but through denial of insurance to sick patients. That's "wrong."