Reverse your decision to deny John Waage Cytoreductive Surgery with Hyperthermic Intraperitoneal chemotherapy (HIPEC)

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Reverse your decision to deny John Waage Cytoreductive Surgery with Hyperthermic Intraperitoneal chemotherapy (HIPEC)

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My name is John Waage. I am a 37 year old loving husband, public school high school band director and music teacher from Brookfield, MA with colorectal cancer that has metastasis to my liver, lungs, abdomen, and outer colon. Since I was originally diagnosed in July 2012 with a sizable tumor in my colon, I have endured 3 surgeries, radiation, several rounds of IV chemotherapy, a year of Avastin, and 9 months of oral chemotherapy.  My surgeries and treatments have taken place at Brigham and Women’s Hospital in Boston, and UMASS Memorial Medical Center in Worcester, MA. My last CT scan, well over two months ago, showed significant growth in a tumor on my liver, as well as the stability of several small lesions on my lungs.  During a surgical procedure on February 4th, 2015 to resect my liver and remove the offending tumor, my surgeon, Dr. Jennifer Lafamina, discovered evidence of cancer on my abdominal wall and on my outer colon.  She consulted with my oncologist, Dr. Vijay Kasturi and fellow surgeon, Dr. Laura Lambert and they decided I was a candidate for Cytoreductive Surgery with Hyperthermic Intraperitoneal chemotherapy (HIPEC).

Horizon Blue Cross Blue Shield of NJ has denied coverage for the HIPEC procedure because according to their medical policy #035, they deem it, “experimental”.  After my surgeon, Dr. Lambert’s peer-to-peer appeal, the procedure was denied again for the same reason. 

Since I was allowed another more formal appeal, My wife Lisa and I spent many days gathering information and with the amazing help of a health advocate, we put together a 55 page document that would prove in every way that this procedure is most definitely not experimental, and is in fact the best course of action for my condition. This document cites an abundance of respected scientific literature that states this is an appropriate surgery, as well as past cases of patients with my condition being approved for HIPEC by many major insurance companies, including Horizon BCBS of NJ.  HIPEC is performed at major cancer centers all over the US and the World. I am lucky to have this option available to me with Dr. Lambert here at UMASS Memorial in Worcester.

To my complete astonishment, despite all the evidence that this procedure is medically necessary for my condition, despite the scientific research, despite the precedent that has been set by insurance companies and Medicare, I was denied again.  The denial was for the same reason, that the treatment was deemed “experimental”. Absolutely no mention was made of any of the evidence we presented to the contradict Horizon BCBS of NJ’s position. There was no indication that the medical reviewer, a primary care physician, even took the presented evidence into account.   

The next step was to initiate an independent review which upheld the denial on the same grounds despite the evidence we originally provided, plus another additional 35 pages of evidence. 

In addition to the appeals department, I had emailed copies of my appeal to ten higher level employees of Horizon BCBS of NJ. None of them even acknowledged receipt of the appeal via an email response, and only three were able to acknowledge receipt through their assistants, only after I followed up with a phone call.  No one has explained to us the details of why they ignored evidence in our appeals. I am confident Horizon Blue Cross Blue Shield of NJ has no interest in the facts.

This is a life threatening situation. According to my doctors and a significant amount of data, Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is the best treatment for colon cancer with metastasis to the abdominal cavity. My wife Lisa and I are very worried that I am not getting the best care possible because an insurance company doesn't want to pay for it. Please sign my petition to convince Horizon Blue Cross Blue Shield of NJ that they need to cover this procedure as medically necessary for me to continue my fight to live. 

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