Bone marrow transplantation (BMT) nurses need
to educate themselves about their patients insurance coverage,
said the Oncology Nursing Society (ONS) at its Eighth Annual Fall
Institute. First, nurses must verify that patients have coverage and
then determine in which of three probable ways the coverage handles
transplants: (1) as medically necessary cancer therapyin which
case, any burden of proof falls on the transplant team; (2) as
excluded under the terms of the policythe policy states that it
doesnt cover any transplants or it covers only certain types
(eg, it covers leukemia but not breast cancer); or (3) as an
experimental or investigational treatmentthe policy states that
it will not cover experimental or investigational therapies or that
it may cover only randomized National Cancer Institute (NCI) clinical trials.
In addition, some insurance companies have contract
agreements with certain transplant centers called centers
of excellence, the only facility where the transplant may be
performed. To perform the transplant elsewhere requires evidence that
the alternative transplant center has good outcomes and that the
procedure can be done at a reasonable price.
Cost-containment measures that insurance companies have adopted
include establishing reasonable and customary fees,
inserting preexisting condition clauses into their policies,
requiring preauthorization and often a second opinion, limiting
coverage to a certain amount, or specifying exclusions for specific
procedures in the policy itself or insisting that transplants be
performed only in their own centers of excellence.
If Coverage Is Denied
Insurance companies will need the target date of the transplant,
relevant patient information, and medical justification information
from the transplant physician(s). The patients nurse should
request written verification of coverage and payment, but if coverage
is denied, there are other options. The denial can be negotiated
diplomatically along these guidelines:
Cooperate with the payors in the insurance company. Dont be
adversarial or insist that the insurer pay for the transplant;
instead, focus on why the patients case is a good one.
Supply medical justification for the procedure.
Appeal quickly. Some insurance companies allow only 60 days between
the denial and appeal.
Speak the insurers language and avoid words like
experimental or investigational. These send
up red flags.
Update protocols and patient consent forms. Always provide current information.
Write an effective appeal letter describing the patients
current condition, history, and why coverage was initially denied.
Give a list of 5 to 10 physicians names as references,
preferably prominent physicians who support the transplant for this
Cite the transplant centers qualifications for the procedure.
If the insurance company still denies coverage, the patient or the
transplant center can appeal to the patients employer to
intervene. If that fails, litigation may be the next step. The threat
of litigation has persuaded many insurance companies to cover a
transplant, especially if there is evidence that its denial is
dominated by the companys economic self-interest.
Alternative Funding Sources
If insurance coverage is denied despite these efforts, patients may
obtain funding by establishing a nonprofit corporation to collect
tax-deductible donations, holding auctions or other public events to
raise money, or soliciting funds through the radio, newspaper, and
Bone marrow transplantation is expensive. Compatibility testing for
BMT costs about $5,000; bone marrow harvest, about $15,000; and the
transplant itself, from $130,000 to $200,000.
The patients and familys lost income are additional costs
that need to be calculated.
Since conventional treatment costs $15,000 to $40,000, there are
increasing efforts throughout the country to ensure coverage for
anyone who needs a transplant instead. The National Association of
Insurance Commissioners is considering a model act for states that
would set a minimum standard of coverage for BMT. Medicaid covers BMT
in most cases for breast cancer; CHAMPUS, the military insurer,
covers transplants for breast cancer if the person is enrolled in an
NCI randomized clinical trial; and the Federal Employee Health
Benefits Program (covering 9 million people in the United States)
covers BMT for breast cancer.