At a recent meeting that I attended it was reported by a nurse that one of her patients with advanced prostate cancer with only a PSA recurrence and lymph node involvement on a scan was rejected by their insurance company for reimbursement for Provenge. The insurance company indicated that to pay for the treatment they would want to have a positive biopsy of the node.
Today I received an email from another advocate I work with sharing a report of a similar experience. The following is her email:
I recently spoke with an oncology nurse who is very knowledgeable re:Provenge, who had a patient with lymphadenopathy as shown on a CT scan – no bone mets. His private insurance in Illinois refused to acknowledge it as metastasis without pathology (biopsy) and refused reimbursement, even after appeal. The patient paid cash for his PROVENGE.
I do not have actual records, and I have not talked with the patient – but the take home message was that “Insurance may not pay for PROVENGE with only lymphadenopathy on CT.” The problem here was with Private Insurance – not Medicare.
I was very concerned about this message, because:
This is not how the phase 3 IMPACT trial was designed (CT lymphadenopathy was “metastasis”) **
I talk with callers every week about PROVENGE, trying to give them accurate information.
There were other clinicians who heard this take-home message, and I’m concerned it’s inaccurate.
I’m concerned that men who are eligible for PROVENGE may be getting reimbursement refused by private in companies.
SO – I am asking for any input – Have you found this to be true or false?
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** “Progressive measurable disease (changes in size of lymph nodes or parenchymal masses on physical examination or x-rays), regardless of changes in PSA, bone scan, or performance status, is adequate for protocol eligibility using conventional solid tumor criteria.”
(Bubley GJ, Carducci M, Dawson N, et al: Eligibility and response guidlines for phase II clinical trials in androgen independent prostate cancer: Recommendations from the PSA Working Group. J Clin Oncol 17:3461-3467, 1999).
I too want to know about other individual’s experience so I can share the information with both other advocates and patients and perhaps work with Dendreon (the manufacturer of Provenge) to rectify this problem. Please let me know if you have only lymphadenopathy diagnosed by CT scan, have private medical insurance and have had any type of insurance company response, either positive or negative.
I look forward to your experiences.
Joel T. Nowak, M.A., M.S.W.