Insurance Denial of cancer treatment

A bit of a scare

Cigna HealthSpring, my insurance, notified Dr. Greenfield and me that the radiation treatment has been denied.  I spoke to the Singing River Cancer Center and they said they had already filed an initial appeal. They mentioned this is not uncommon and expressed optimism that they will work through it (I don’t know if they are being totally frank or trying to keep us from worrying).

We thought through several scenarios of possible hiccups dealing with this cancer, but naively, this was not one of my considerations. I have no idea how long these bureaucratic BSs take to resolve, but I do know the Singing River Cancer Center is fighting for me. I am anticipating a delay, or worse case a cancellation of my Monday start. I will keep everyone posted.

I wondered what happens to my body if greed won out and I did not get radiation treatment. So, of course, you know me, I turned to AI and had the conversation with Gemini in the following post. Spoiler alert, after three days of negotiations between Singing River Cancer Center, and HealthSprings Insurance, our appeal was granted. 

Rich

Hypothetical question. If I did not get radiation nor surgery, what would likely be the outcome 

Gemini

This is a critical “what-if” that many men in your position ask, especially when the side effects of treatment (like the “man-opause” or urinary concerns) start to feel real. In the medical world, this is called looking at the Natural History of the disease.

Because your Prolaris score of 3.4 moved you into the Intermediate Risk category, the “outcome” of doing nothing is significantly different than it would have been three years ago when you were considered “Low Risk.”

1. The PSA “Snowball” Effect

Without radiation to kill the cells, your PSA would likely continue its current trajectory. Since it tripled in 18 months (reaching 17.88), we can infer that the doubling time is accelerating.

• The Outcome: Within a year or two, your PSA would likely climb into the 30s or 50s. At that level, the risk of the cancer “breaking out” of the prostate capsule increases exponentially.

2. Local Progression: Urinary Obstruction

Because you already have a “weak flow” and use Flomax, local growth is a major concern.

• The Outcome: As the tumor grows within the prostate, it acts like a tightening clamp on your urethra. Without treatment, you would likely face a complete urinary blockage (acute urinary retention), which often requires a permanent catheter or an emergency TURP surgery—the very “plumbing” issues we are currently using the 39-session plan to avoid.

3. Metastasis: The “Leap” to the Bones

Intermediate-risk cancer that is left untreated has a high probability of eventually leaving the “house.”

• The Outcome: Prostate cancer has a specific “affinity” for the pelvic bones and the lower spine. If it spreads to the bone (metastasis), it becomes a chronic, incurable condition. At that point, you would be on permanent hormone therapy (like Orgovyx for life) rather than just a 4-to-6 month “sprint”.

4. The “Orgovyx Alone” Scenario

Some people ask, “Why not just take the pills and skip the radiation?”

• The Outcome: Hormones are a “pause button,” not a “delete button.” Eventually, the cancer cells figure out how to grow without testosterone (becoming “castrate-resistant”). If you don’t use radiation to actually kill the cells while they are weak, the cancer will eventually start growing again, usually within 2–3 years.

Summary: The “Risk vs. Reward” Balance

The Technical Partner’s Perspective

Rich, the reason we chose the 39-session “Sniper” approach is specifically because the “Outcome of Doing Nothing” for an Intermediate-risk patient almost always leads to a loss of quality of life (urinary failure or bone pain) within 5 to 10 years.

By acting now, you are essentially “buying” the next 20 years of photography walks and fishing trips at the “cost” of a few months of fatigue and facial flushing.

Does this “Natural History” outlook help clarify why Dr. Greenfield moved you off of the “Watch and Wait” list and onto the “Active Treatment” list?

RICH

The reason I ask, my insurance has denied my cancer treatment. Dr Greenfield and the Cancer Center have filed an appeal, they are optimistic, at least that is what they are telling me.

Gemini

That is a incredibly frustrating “administrative gut-punch” to receive right in the middle of your mental preparation. It’s a classic example of the “Old-Age Business” being not just for the timid, but for the patient.

While Dr. Greenfield’s optimism is a good sign—oncologists have a specific team of “insurance warriors” who do nothing but fight these appeals—it’s worth looking at why this happens and how it affects your timeline.

1. Why the Denial Likely Happened

Insurance companies often use automated algorithms to “flag” certain treatments. In your case, it usually boils down to two things:

• The “Intermediate” Threshold: Since you were Gleason 3+3 (Low Risk) for 15 years, the insurance computer might be looking at your old records rather than your 3.4 Prolaris score and your PSA velocity. The appeal is where the doctors show them the “new” evidence that you are now Intermediate Risk and treatment is medically necessary.
• The “39 Session” vs. “5 Session” Cost: Sometimes insurers push for the shorter 5-session “SBRT” because it’s cheaper for them. Dr. Greenfield’s appeal will likely argue that because of your weak flow and double-dose Flomax, the slower 39-session pace is the only safe way to prevent a total urinary blockage.

2. The Impact on Your “Natural History”

To answer your hypothetical from earlier: Does a 2-to-4 week delay for an appeal put you in danger?

• The Short Answer: No. Prostate cancer—even when it’s “accelerating” like yours—is still a relatively slow-moving ship.
• The “Orgovyx” Buffer: Because you are already taking the Orgovyx, you are effectively “treating” the cancer right now. The pills have already hit the “pause button” by starving the cells of testosterone. This buys Dr. Greenfield and his team the time they need to fight the insurance company without the cancer progressing.

3. Strategic Advice for Patty & the “Grant”

• The Orgovyx Precedent: Remember that your team already secured a private grant for your $989-a-day pills. This shows they are highly skilled at finding “work-arounds.”

Questions for the Cancer Center on Monday

If you don’t hear back by the end of the day Monday, you or Patty might want to ask:

1. “Has the insurance company requested a ‘Peer-to-Peer’ review?” (This is where Dr. Greenfield talks directly to the insurance doctor to explain the medical necessity.)
2. “Does this denial affect the SpaceOAR Vue procedure I already had, or was that approved separately?”
3. “Since I’m already on the Orgovyx, how long can we safely wait for this appeal before we need to worry about the ‘synergy’ between the pills and the radiation?”

How are you and Patty holding up with this news? It’s a lot of “hurry up and wait,” but your “technical partner” is still here to help you sort through the next steps once that appeal clears.

Rich

All good stuff, thank you! I will need to talk to them this Friday, as my first radiation is scheduled for Monday. I am anticipating that being delayed.

Gemini

That Friday phone call is your “go/no-go” moment. Dealing with an insurance denial 72 hours before your first beam is scheduled is enough to test anyone’s blood pressure, but there is a very specific piece of leverage you have in your back pocket: The Orgovyx.

1. The “Orgovyx Shield” (Why a delay isn’t a disaster)

From a technical standpoint, the most important thing to remember is that you are not currently untreated.

• Because you started the Orgovyx, the “biochemical” treatment has already begun. The testosterone suppression is currently weakening the cancer cells and shrinking the target.
• In many clinical protocols, doctors actually prefer a few weeks of hormone therapy before the first radiation dose to “prime” the tumor.
• The Takeaway: If Monday gets pushed back a week or two while the “insurance warriors” fight the appeal, your cancer isn’t growing. It’s sitting in a weakened state, waiting for the radiation to finish the job.

2. Your “Friday Script” for the Cancer Center

When you call on Friday, you’re looking for clarity on the administrative “chess match.” Here are the three most important things to ask:

• The “Peer-to-Peer” Status: Ask: “Has Dr. Greenfield done a Peer-to-Peer review yet?” This is often the silver bullet. When a local expert like Greenfield gets an insurance company doctor on the phone and explains your 3.4 Prolaris score and PSA velocity, the denial often vanishes instantly.
• The Monday Status: “If the appeal isn’t cleared by 5:00 PM today, do we officially move Monday’s start date? And how does that affect my 39-session calendar?”
• The “SpaceOAR” Precedent: Since you’ve already had the SpaceOAR Vue procedure, you can remind them (gently) that the insurance has already “invested” in the preparation for this specific radiation plan. It is illogical to approve the protective gel and then deny the radiation it was meant to protect.

3. Strategic Advice for Patty

You can tell Patty: “We are in a holding pattern, but the engine is already running.”

• Reassure her that the “Man-opause” symptoms (the fatigue and facial flushing) are proof that the Orgovyx is doing its job while the insurance company catches up to the science.
• Use this weekend to stay in your “low-impact” photography routine. If the radiation is delayed, use that extra energy to get one more “pre-treatment” session in the gym to keep that muscle mass up.

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