New Medicare Program: Full List of Services That Will Need Prior Approval

[Ms. Toad]

68. That's the general basis for my personal concern with the skin and tissue substitutes

I was in surgery about a week after my diagnosis (there were was an earlier surgery which removed most of the lump - because they believed it was benign). So the surgery was to remove the remnant of a very aggressive cancer, which had been doubling every 2-3 weeks. Turns out the most aggressive portion was the deepest (which hadn't been removed), so it needed to be out quickly. Even without knowing the portion remaining was the most aggressive, the surgeon was annoyed that I wasn't able to have it out more quickly.

I also had to have an MRI before the surgery to make sure there weren't any skip tumors nearby that just weren't palpable yet. (This particular cancer skips over healthy tissue - the 1 cm margin is because at that distance they get about 98% of any cells/newly established tumors which have jumped over healthy tissue into nearby tissue).

They initially insisted I would need to wait 10 days for pre-approval for an MRI before scheduling surgery (I was on employee insurance at the time). When pressed on the matter, after speaking with a few different departments, I learned that the Cleveland Clinic had the ability to do their own pre-authorization for MRIs. So that wait disappeared.

Because the wound left was about 5" in diameter, and they needed to be positive they had not only all of the tumor, but a cm of cancer-free tissue around the tumor, it couldn't be permanently closed until after a 2-3 week period for pathological examination. Pre-authorization was not required for the skin substitute - BUT - it was denied by the insurance company after the fact (and approved on appeal a month or two later). The surgeon would not have done the surgery without a skin substitute for that period of time. Since it was denied after the fact, I have no reason to believe there would be any different result had the review been done in advance, or by a Medicare AI-bot, rather than a private insurance review. That would have imposed an even longer wait period prior to surgery.

My theoretical position about this new imposition wouldn't have been very different - but my personal experience with pre-authorization (generally) and with one of the products in this list gives me a very personal reason to be angry about it.

My diagnosis was 5 years and 22 days ago. I've been NED (no evidence of disease) for 5 years and 13 days. In about a week, I get to drop from semi-annual surveillance to check for lung metastasis to biannual surveillance for the next decade or so. (With this disease, the frequency of checks start at quarterly, then drop to semi-annual, then (usually) to annual for the rest of my life. In my case, I found the tumor early, so my doctor believes the chance of late metastasis will be near zero after 15 years of surveillance.