WHAT WE ARE UP AGAINST:

Glen's insurance company is basing their decision to deny treatment based on the mSMART criteria included in the policy agreement.  Above is a chart that I found online that maps out what they are specifically referring to.

In the Intermediate-Risk column Glen has the * Cytogenetic Deletion 13 or hypodiploidy, and in the High-Risk column he has the * FISH, Del 17p.  This puts Glen in less that 1% of all myeloma patients.  THIS, is why they are stating that he is "too high-risk" and does not qualify for the second SCT that he needs to prolong his life.

FRUSTRATING to say the least.

We  submitted our request for arbitation yesterday.  Hopefully that will be scheduled soon. 

While life is a challenge with cancer on a daily basis, today I send prayers for all those who are being affected by Hurrican Irene.  May God protect, guide and direct you during this time.

Keep Strong,
Vannette

ONE, TWO, THREE, FOUR: DENIALS

Glen received word by way of a telephone call early Friday morning the 12th that yet again  his request for approval for a second ASCT was denied.

Here are portions of a signed letter that came by email at our request:

Dear Mr. Ross:

The HIPUtah 3rd Level Appeals Committee ("Committee") met on August 10, 2011 to consider your appeal in regard to the denial of benefit coverage under your HIPUtah plan for a second autologous stem cell transplant.  Please know that this Committee reviewed every aspect of your appeal, deliberated on your request for some time, and took into account the emotional and physical suffering you are experiencing.

..............All prior reviews denied your requested services based on your condition not meeting specific criteria as established in SelectHealth's Bone Marrow Transplantation Policy #105, under Human Stem Cell Transplantation.  This Committee feels that our administrator, SelectHealth, conducted due diligence in the review of this matter.

The Committee thoroughly reviewed studies presented in the appeal along with SelectHealth's current policy, as stated above, and other scientific documentation presented on this medical service.  In addition we reviewed your request, your medical information, and the additional information provided by Dr. Tricot and yourself, relating to your appeal.  Based on this information, the Committee voted to deny the appeal based on you not being a candidate for a second transplant based on the mSMART criteria as you are considered a high risk individual with a deletion of 17p13.  This Committee feels that SelectHealth has a solid policy on this issue which was derived on evidence-based medicine.  In addition, outside entities have reviewed the appeal and presented a determination with the same conclusion.  It was determined that no new significant data or information was presented that would support us covering of the second transplant at this time.

If you have further . . . . . . . .

If you wish to continue your appeal of the denial of coverage, a voluntary review through arbitration is available to you under your contract.  Arbitration in the final level of appeal through which a dispute may be settled.   . . . . . . .

mSMART:  Mayo Stratification for Myeloma And Risk-adapted Therapy

One SCT is known as the "Mayo" method while a double or tandem SCT is known as the "Arkansas" method.  This Committee looked at the Mayo data and said no new "significant" data was presented.  I beg to differ.  Dr. Tricot has patients that are still living 10 years post-transplant.  Glen was placed in a study so that "data" will be available.  His "data" cannot continue if treatment is denied.  He will be removed from the study. 

I am too upset to continue on with this.  It is 12:35am.  Obviously I am not asleep.  I feel like the woman in the commercial that calls in and gets "PEGGY", asks for a supervisor, gets transferred a number of times until she gets "PEGGY"  (Peggy with a beard, Peggy), then stomps her foot while screaming

     "COME ON"

Vannette