A huge robotic machine has helped some doctors combat cancer in difficult to treat cases, but not everyone with insurance has been covered for it.
There was always that little bit of dread in the back of Fred Kinder's mind. His father had prostate cancer in his early 50s and Fred knew it might hit him early too.
But it was still a shock when Stanford confirmed the diagnosis last summer. Fred was 62 years old with a wife and 8-year-old son.
Karen Vinci was 53 years old when doctors said she had five weeks to live. The reason was a grapefruit-sized tumor had wrapped itself around her bile duct, just below the liver. That was in 2003. Somehow she survived the major surgery and made it through chemo and radiation.
But last year the cancer came back—a rare and inoperable tumor.
"Pretty severe. Life threatening," Vinci said. "It was a life and death situation."
But in both cases, a high-tech treatment offered hope.
It's called the CyberKnife—a huge robotic machine converted from an automobile assembly line. Despite its name, there is no cutting. The CyberKnife shoots out thread-like beams of intense radiation from hundreds of angles. Using computer guidance, the laser beams come together directly on the tumor—burning just the cancer without damaging healthy tissue.
An entire team of doctors at the University of California San Francisco Medical Center decided that the CyberKnife offered the only treatment that could save Vinci's life.
"Without it," said UCSF radiation oncologist Kim Huang, "it's impossible to have a cure in her case."
But then Kinder and Vinci got letters from their health insurance company—Blue Shield—denying payment for the procedure.
"I was shocked when I was denied," Kinder said, wiping away tears. "I was shocked."
"It was devastating," Vinci said. "Because here you are in treatment and they're saying no."
Why the rejection? Because Blue Shield said the CyberKnife is an "experimental and investigational" treatment—a term sometimes used by health insurance companies to claim that there isn't enough evidence that a treatment works.
Dr. Huang disagrees.
"There is medical evidence supporting the way we're using it—CyberKnife—to treat tumors in the body," Dr. Huang said.
In fact, in 1999 the Food and Drug Administration approved the CyberKnife for brain surgery; then in 2001 for treatment of tumors "anywhere in the body." Medicare, another federal agency, pays for all CyberKnife treatments in California. And there are more than 80 CyberKnife centers around the country.
CBS 5 Investigates asked Dr. Huang if the insurance company offered an alternative to the CyberKnife after they deemed the treatment was experimental and investigational treatment.
"No," Dr. Huang replied. "They don't think it's their job to offer an alternative. That's what I asked them, when I talked to the medical director at the insurance company. And I said, 'What kind of treatment do you want her to get then?'"
Asked about their response, Dr. Huang just shrugs.
"They don't answer," she said.
Vinci and her husband fought back, through two appeals, and thought they would be covered—until the very day she went for her CyberKnife treatment and found that Blue Shield was still refusing to pay.
"I was prepared to go into this treatment," Vinci said, "and now all of a sudden it's about money and I'm fighting for my life."
One health insurance expert CBS 5 Investigates spoke to said the very definition of experimental or investigational is a "moving target," with each insurance company essentially making up its own rules.
Healthcare advocate Jerry Flanagan of the group Consumer Watchdog said, "Insurance companies have a financial incentive to deny coverage and call it experimental and investigational."
Flanagan believes Blue Shield's denials for Karen Vinci and Fred Kinder are arbitrary and may violate state law.
"The bottom line here is that it's not up to the insurance company to decide who gets what treatment or whether the CyberKnife should be provided," Flanagan said. "The law requires that the doctor gets to decide, as long as the insurance company doesn't have a better option for you."
So what does Blue Shield say? The company refused an on-camera interview. But they sent CBS 5 Investigates a statement saying it relied on the "best scientific evidence" in denying Kinder and Vinci's claims—and that "standard radiation therapy is as effective as the more complex treatment for these patients."
But Kinder said, "It doesn't make sense that insurance companies can be your doctor and determine what's best for you—when it's not the best."
After fighting for six months, Fred Kinder appealed the decision to California's Department of Managed Health Care—and won. The state said the CyberKnife "is likely to be more beneficial than any available standard therapy."
As for Karen Vinci, she eventually won her state appeal too.
And even better news, she said, "Exactly one year after having my last CyberKnife treatment, I am now cancer free."
And Dr. Huang can't suppress a grin as she added, "I think the CyberKnife treatment gave her another chance for life. And, yeah—I saved her life this time."
If an insurance company denies coverage for a treatment, you can appeal to the state. But a consumer watchdog tells us that, more often than not, patients lose the appeal.
The following is a statement from Blue Shield of California representative:
We recognize that patients trust their doctors to recommend the most appropriate treatment for their condition and expect their health plan to pay for it. We provide comprehensive coverage for radiation therapy, which is the standard treatment for these types of cancer. Our medical policy, which is based on the best scientific evidence and clinical studies, determined that standard radiation therapy is as effective as the more complex treatment for these patients.
In questions involving emerging medical technologies, it is not unusual for experts to disagree. Two of the physicians who reviewed these cases under the state's Independent Medical Review process agreed with us; four did not. In light of that outcome, we promptly agreed to cover this treatment and wish both patients a complete and speedy recovery.
Alan Sokolow, MD
Chief Medical Officer
There was always that little bit of dread in the back of Fred Kinder's mind. His father had prostate cancer in his early 50s and Fred knew it might hit him early too.
But it was still a shock when Stanford confirmed the diagnosis last summer. Fred was 62 years old with a wife and 8-year-old son.
Karen Vinci was 53 years old when doctors said she had five weeks to live. The reason was a grapefruit-sized tumor had wrapped itself around her bile duct, just below the liver. That was in 2003. Somehow she survived the major surgery and made it through chemo and radiation.
But last year the cancer came back—a rare and inoperable tumor.
"Pretty severe. Life threatening," Vinci said. "It was a life and death situation."
But in both cases, a high-tech treatment offered hope.
It's called the CyberKnife—a huge robotic machine converted from an automobile assembly line. Despite its name, there is no cutting. The CyberKnife shoots out thread-like beams of intense radiation from hundreds of angles. Using computer guidance, the laser beams come together directly on the tumor—burning just the cancer without damaging healthy tissue.
An entire team of doctors at the University of California San Francisco Medical Center decided that the CyberKnife offered the only treatment that could save Vinci's life.
"Without it," said UCSF radiation oncologist Kim Huang, "it's impossible to have a cure in her case."
But then Kinder and Vinci got letters from their health insurance company—Blue Shield—denying payment for the procedure.
"I was shocked when I was denied," Kinder said, wiping away tears. "I was shocked."
"It was devastating," Vinci said. "Because here you are in treatment and they're saying no."
Why the rejection? Because Blue Shield said the CyberKnife is an "experimental and investigational" treatment—a term sometimes used by health insurance companies to claim that there isn't enough evidence that a treatment works.
Dr. Huang disagrees.
"There is medical evidence supporting the way we're using it—CyberKnife—to treat tumors in the body," Dr. Huang said.
In fact, in 1999 the Food and Drug Administration approved the CyberKnife for brain surgery; then in 2001 for treatment of tumors "anywhere in the body." Medicare, another federal agency, pays for all CyberKnife treatments in California. And there are more than 80 CyberKnife centers around the country.
CBS 5 Investigates asked Dr. Huang if the insurance company offered an alternative to the CyberKnife after they deemed the treatment was experimental and investigational treatment.
"No," Dr. Huang replied. "They don't think it's their job to offer an alternative. That's what I asked them, when I talked to the medical director at the insurance company. And I said, 'What kind of treatment do you want her to get then?'"
Asked about their response, Dr. Huang just shrugs.
"They don't answer," she said.
Vinci and her husband fought back, through two appeals, and thought they would be covered—until the very day she went for her CyberKnife treatment and found that Blue Shield was still refusing to pay.
"I was prepared to go into this treatment," Vinci said, "and now all of a sudden it's about money and I'm fighting for my life."
One health insurance expert CBS 5 Investigates spoke to said the very definition of experimental or investigational is a "moving target," with each insurance company essentially making up its own rules.
Healthcare advocate Jerry Flanagan of the group Consumer Watchdog said, "Insurance companies have a financial incentive to deny coverage and call it experimental and investigational."
Flanagan believes Blue Shield's denials for Karen Vinci and Fred Kinder are arbitrary and may violate state law.
"The bottom line here is that it's not up to the insurance company to decide who gets what treatment or whether the CyberKnife should be provided," Flanagan said. "The law requires that the doctor gets to decide, as long as the insurance company doesn't have a better option for you."
So what does Blue Shield say? The company refused an on-camera interview. But they sent CBS 5 Investigates a statement saying it relied on the "best scientific evidence" in denying Kinder and Vinci's claims—and that "standard radiation therapy is as effective as the more complex treatment for these patients."
But Kinder said, "It doesn't make sense that insurance companies can be your doctor and determine what's best for you—when it's not the best."
After fighting for six months, Fred Kinder appealed the decision to California's Department of Managed Health Care—and won. The state said the CyberKnife "is likely to be more beneficial than any available standard therapy."
As for Karen Vinci, she eventually won her state appeal too.
And even better news, she said, "Exactly one year after having my last CyberKnife treatment, I am now cancer free."
And Dr. Huang can't suppress a grin as she added, "I think the CyberKnife treatment gave her another chance for life. And, yeah—I saved her life this time."
If an insurance company denies coverage for a treatment, you can appeal to the state. But a consumer watchdog tells us that, more often than not, patients lose the appeal.
The following is a statement from Blue Shield of California representative:
We recognize that patients trust their doctors to recommend the most appropriate treatment for their condition and expect their health plan to pay for it. We provide comprehensive coverage for radiation therapy, which is the standard treatment for these types of cancer. Our medical policy, which is based on the best scientific evidence and clinical studies, determined that standard radiation therapy is as effective as the more complex treatment for these patients.
In questions involving emerging medical technologies, it is not unusual for experts to disagree. Two of the physicians who reviewed these cases under the state's Independent Medical Review process agreed with us; four did not. In light of that outcome, we promptly agreed to cover this treatment and wish both patients a complete and speedy recovery.
Alan Sokolow, MD
Chief Medical Officer
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