Insurances refuse to reimburse for life-saving treatment

Betty Kruk says both Medicare and her private insurance refuse to reimburse her for the PET scan that saved her life.

Her cancer first appeared in her left breast in July of 1997. It was successfully treated with surgery and special immune therapy treatments, and she remained cancer free until September of last year when blood tests during a checkup indicated a cancerous growth.

"The blood test indicated that there was some type of malignant growth, but it didn't tell the physician where the cancer was located," she said.

Reno oncologist Dr. James Forsythe ordered a battery of tests to pinpoint the location of the malignancy, including mammography, bone scan, ultrasound and chest x-ray.

When all came back negative, Forsythe ordered the new PET (Positron Emission Tomography) scan, a procedure that showed a malignant tumor in Kruk's right breast.

Tomography measures metabolic rate, thereby analyzing the function and physiology of any tissue including tumors, heart muscle and brain matter.

It's a valuable tool that helps physicians understand the disease process thereby aiding in diagnosis, staging, and treatment of most types of cancer, according to Dr. David Landis, radiologist with Great Basin Imaging in Carson City.

Kruk has been successfully treated with immune therapy, and checkup has indicated she has, thus far, won the battle.

But after months of providing the facts to her insurance carriers, Government Employees Hospital Association and Medicare, both have refused to reimburse for the PET scan that pinpointed the location of her cancer.

Medicare currently covers use of this technology for other cancers. Lung, colorectal, melanoma and esophageal cancers, as well as Hodgkins' disease, are covered by Medicare, but not tumors of the breast.

Kruk calls this failure to reimburse discriminatory.

"Rather than a patients' bill of rights, we need more control over insurance companies so they can't do what they do," Kruk argued.

A petite gray-haired woman with large, pale blue eyes, Kruk is all energy and twinkle as she fields questions in the Carson City home she built and designed.

She is no stranger to the insurance game. An employee in the insurance industry in the 1950s, she currently helps her daughter, local chiropractor Dr. Lisa Getas, with insurance claims and she said the business has changed dramatically - for the worse - in the last 60 years.

After exhausting all alternatives, Kruk wrote U.S. Sen. Harry Reid and Sen. John Ensign.

"I really thought through Ensign's office I would get results," she said. "But after months their bottom line to me was, 'We can't make make them pay.'"

Tomography is a technology that has been around since the early 1980s, according to Dr. David Landis, a radiologist. And it is proven to be significantly more effective than standard mammography in detecting breast cancer, according to literature distributed by Great Basin Imaging in Carson City.

Debbie Platt, operations director for Great Basin Imaging, said that to qualify for Medicare reimbursement, new technologies must go through extensive testing to evaluate whether the procedure will have an impact on a patient's outcome, or help clinicians.

"If they consider it experimental or ineffective, or it doesn't aid in treatment or long-term outcome, they won't reimburse," she said.

A call to the Medicare information line yielded no information. Crystal Lee said she was not qualified to say why Medicare does not reimburse for breast PET scans and she would not refer to another source.

After months of wrangling, Medicare has granted Kruk a hearing on the matter, which is pending. But in a letter from Government Employees Hospital Association dated July of 2001, Sally Allin, a registered nurse with the organization, refused the claim, calling the procedure experimental, unacceptable and not a medical necessity.

"Should you choose to pursue this matter, you have the right to file a suit in federal court," she wrote.