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Payment asked for radiation therapy

Tuesday, April 23, 2002

By Christopher Snowbeck, Post-Gazette Staff Writer

A Clarion County man is asking a federal judge to force Highmark Blue Cross Blue Shield to pay for advanced radiation treatments of his head and neck cancer.

Robert Bowersox, 58, was diagnosed with cancer earlier this year and had much of the tumor removed during surgery five weeks ago.

He is supposed to receive intensity-modulated radiation therapy at UPMC Shadyside starting this week, but Highmark denied coverage and rejected Bowersox's latest appeal on Friday, according to Bowersox's attorney, Jim Zeszutek.

IMRT, as the treatments are referred to, has been recommended by some doctors as the treatment of choice for patients with prostate cancer, some head and neck cancers and brain tumors. In head and neck cancer patients, IMRT offers the chance of treating the cancer without damaging the salivary glands.

"This prevents the patients from having radiation-induced xerostomia, a condition characterized by the total or almost total absence of saliva where the mouth becomes totally dry and it is extremely difficult to speak for prolonged periods of time," said Dr. Shalom Kalnicki, vice chairman for clinical affairs at UPMC Shadyside's radiation oncology department.

Zeszutek said last week he had intervened on behalf of a prostate cancer patient whose claim for IMRT was initially denied, and Highmark reversed its decision.

Highmark's policy is out of step with that of other carriers, including Medicare, that pay for the treatments, Zeszutek said, and break from the insurer's past practice of paying for IMRT.

Denise Grabner, spokeswoman for Highmark, said the insurance company has generally considered IMRT an investigational treatment and therefore hasn't covered it as a matter of course. Earlier this year, a technology review panel convened by the national Blue Cross Blue Shield Association also determined the treatments are investigational, Grabner said.

Dr. Russell Fuhrer, a radiation oncologist at Allegheny General Hospital, said he couldn't comment on any particular case, but said it's understandable why health plans would scrutinize claims for IMRT. Medicare pays more than four times as much for IMRT as it does for conventional treatments, Fuhrer said.

"Highmark is not at all alone in this," he said. "There are a number of payers balking at this reimbursement."

But there's no denying that Bowersox, a retired high school teacher, is facing a terrible dilemma this week. He knows from a long-time friend who had a similar cancer and underwent conventional treatment what's at stake.

"He has made the best of his life with traditional radiation treatment, but his wife occasionally has to perform the Heimlich maneuver on him and he has trouble speaking," Bowersox said. "It seems unconscionable to me that they won't pay for this."

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