Previous Excerpt 14 “Bad Medical Story — Shock and Awe”
If your requested treatment is denied because it is out-of-network, you will need to discredit the in-network “expert” to whom they referred you. You must give them compelling reasons why you shouldn’t have to go to the in-network specialist for your treatment.
If your treatment is denied because it is “experimental/investigational” or “not medically necessary,” you must prove to them that their in-network specialists and treatments are not going to cure you, and will probably harm you.
Either way, you are going to have to discredit the in-network talent.
Two Scenarios
People often ask me, “My oncologist referred me to a local surgeon who is contracted with Acme Insurance. I already know that I want to get to Dr. Expert. I am going to write an appeal. Do I have to go to the trouble to consult with the Acme expert?”
If you want to write a powerful appeal—and if you have the time and energy—the best choice is to see the Acme surgeon in person. Even better? Bring a small recording device, ask his permission, and record the consultation.
Why? You already know the answer from writing your Bad Medical Story. If you visit an unqualified doctor in person, he is going to make all sorts of off-the-cuff, unwise, ill-considered remarks. Those remarks are going to be gold nuggets for your appeal.
Sometimes, of course, there is no time to see the in-network “experts” to whom we have been referred.
In the first sample, I will show you how to dispose of the in-network expert—without ever seeing him in person.
ACME SURGEON NOT QUALIFIED
______________________________________________________________________________
When we finally came to a correct diagnosis—appendix cancer with peritoneal spread—Acme oncologist Dr. Ward referred my to surgeon Dr. Ron Ryan, saying, “He is a fine surgeon. I would send my family member to him.”
Dr. Ron Ryan is a not a specialist in appendix cancer. He is not a specialist in abdominal cancers. He is not even a G.I. surgeon. Dr. Ryan—the physician to whom I was referred for this extraordinarily complex abdominal surgery and HIPEC—is a breast cancer surgeon. He has no qualifications, scant experience, and no documented good outcomes with cytoreductive surgery.
Dr. Ryan recently took providerships with Acme, Regence, Blue Cross/Blue
Shield, Group Health, and United Healthcare … and became the one insurance provider surgeon at the University of Colorado Medical Center who is now these surgeries.
(Att. x, Dr. Ryan’s resume)
1. Dr. Ryan lacks experience.
After studying 323 cytoreductive procedures, Dr. RM Smeenk et al, Department of Surgery, Netherlands Cancer Institute conclude:
“The peak of the learning curve, graded by the percentage of complete cytoreductions, was reached after approximately 130 procedures.” (Learning curve of combined modality treatment inperitoneal surface disease, RM Smeenk et al.)
Dr. Ryan has performed 23 of these surgeries.
Dr. Sugarbaker has performed over 1500 of these surgeries.
2. Dr. Ryan is a breast cancer surgeon.
Dr. Ryan is a breast cancer surgeon whose stated specialty is “cancer surgery.”
Dr. Sugarbaker is a G.I. surgeon, whose specialty is appendix cancer.
3. Dr. Ryan does not deliver HIPEC by open perfusion.
Dr. Ryan does not deliver the HIPEC by the open “coliseum” technique,
which has been documented to have a significant effect on outcomes:
After the cytoreduction has been made visibly complete, it is invariably true that invisible to the naked eye, an immense number of cancer cells remain within the peritoneal cavity. Tumor manipulation, transected lymphatic ducts leaking tumor cells throughout the procedure, and small tumor nodules remaining on the abdominal and pelvic surfaces of organs not amenable to peritonectomy procedures, namely small bowel, make necessary theimplementation of some method that will eradicate residual tumor cells. Another well-known site for persistent disease is the suture lines that are an ideal site for cancer cell implants.
Tumor cell entrapment occurs on these raw surfaces with fibrin accumulating and tissues compressed together by stitches or staples. Suture lines are at high risk for recurrence if constructed before the HIPEC.
HIPEC using an open technique employs mechanical, physical, and chemical effects to eradicate residual cancer cells after cytoreductive surgery. A mechanical effect to eradicate cancer cells trapped in fibrin and tissue debris takes place during 90 minutes of continuous rubbing and washing of the intraabdominal surfaces. Heat, a physical effect, promotes cell death by various mechanisms affecting nucleic acids, cell membranes, and the cytoskeleton.
(Christophi C, Winkworth A, Muralihadaran V, Evans P. The treatment of malignancy by hyperthermia. Surg Oncol 1998; 7:83-90.)
Dr. Sugarbaker pioneered and uses the open “coliseum” technique.
4. Dr. Ryan does not do the four days post-operative HIPEC.
Dr. Sugarbaker’s treatment includes the four days post-operative HIPEC. The
additional perioperative chemotherapy has been demonstrated to improve
outcomes:
In the first five postoperative days, the patient receives normothermic intraperitoneal paclitaxel (20-40 mg/m2 per day), with the goal of consolidating the intraperitoneal chemotherapy treatments. Systemic paclitaxel has been used to treat advanced ovarian cancer alone and in combination with other drugs. In phase III clinical trials, the combination resulted in improved response rates and also improved survival.
(Armstrong DK, Bundy G, Wenzel L, et al. Intraperitoneal cisplatin and paclitael in ovarian cancer. N Engl J Med 2006; 354:34-43.)
5. Dr. Ryan has never studied or published on appendix cancer.
Dr. Ryan’s resume states that he has “published numerous articles on a
wide range of cancer topics.” Of Dr. Ryan’s ten published articles, two are
about pancreatic cancer, three are about liver cancer, and two are about
gallstones. The other three articles are about malpractice and legal issues. No articles about appendix cancer.
253 of Dr. Sugarbaker’s 452 peer-reviewed journal articles and studies, treat all aspects of appendix cancer, cytoreductive surgery, and HIPEC.
6. Dr. Ryan has no documented good outcomes over eight years.
Dr. Sugarbaker has well-documented outcomes over twenty-eight years.
You do not have to see an in-network “expert” in person, in order to get what you need to discredit him in your appeal. You just need to do three things:
1. Read his resume
2. Check his list of published papers
3. Call his office and ask a few questions
Read his resume
I am constantly telling people, “If a doctor is going to operate on you, or prescribe a drug with side effects—you need to go online, find his curriculum vitae, and read
it.”
People often dismiss this advice, “What would I find there? I don’t care about his
resume.”
I have news for you. Reading a doctor’s resume could save your life.
Consider the complex abdominal surgery and HIPEC that is the subject of this sample appeal. One day, a few years ago, I heard of a new surgeon who had hung out his shingle to do this treatment. Several patients had either been to him, or were planning to go.
It took me five minutes to pull up his curriculum vitae, and find out that he was a thoracic surgeon, not a G.I. surgeon. That’s a chest surgeon, people. Wrong part of the body.
Always read your doctor’s resume.
I found one huge gold nugget in “Dr. Ryan’s” resume. He is a breast cancer
surgeon. Wrong part of the body, dude.
Search his published papers
In Chapter 8, I explain how to find the world’s best database of medical journal articles.
Just go to the NIH website: http://www.ncbi.nlm.nih.gov
Your goal is to prove how puny Dr. Ryan’s body of published work is, and that he has never published any papers or studies about your treatment of choice.
Just type his name in the search box. Last name, first name, middle initial if you have it. For our case, you would type in “Ryan R”:
Dr. Ryan has never studied or published on appendix cancer.
Dr. Ryan’s resume states that he has “published numerous articles on a
wide range of cancer topics.” Of Dr. Ryan’s ten published articles, two are
about pancreatic cancer, three are about liver cancer, and two are about
gallstones. The other three articles are about malpractice and legal issues. No articles about appendix cancer.
253 of Dr. Sugarbaker’s 452 peer-reviewed journal articles and studies, treat all aspects of appendix cancer, cytoreductive surgery, and HIPEC.
I show that Dr. Ryan has never published a paper about appendix cancer, or about this treatment. Then, I rub his nose in it a bit by pointing out that he has seriously overstated his publishing prowess. Ten articles do not constitute “numerous articles on a wide range of cancer topics.” Embarrassing.
I also take great delight in adding that three of his papers were about malpractice and legal topics. Gee, there must be a reason why Dr. Ryan is so interested in legal issues.
Call his office and ask a few questions
I was able to thoroughly rule out and discredit Dr. Ryan in my appeal—just by reading his resume, and calling his office and asking a few questions.
I presented myself as a potential patient, then asked if I could ask a few questions.
The answers that I got allowed me to compare and contrast his treatment methods and his lack of experience to Dr. Sugarbaker, my expert-of-choice.
Dr. Ryan came out looking pretty inexperienced, unqualified, and downright
dangerous.
All that I asked was:
1. How many of these has Dr. Ryan done? (23)
2. How are they doing? (We don’t know)
3. Does he do the HIPEC by open perfusion? (No)
4. Does he do the four days post-op IP chemo? (No)
So, for your own case—simply ask about numbers (how many), and about
outcomes (how are they doing?). Then ask a few pertinent questions which will reveal that he will treat you differently and in a less effective manner than your expert-of-choice.
Go for the consult, and put the answers in your appeal
On page 77, I share an example of how to write your section discrediting the in- network specialist, after you have met with him in person.
Usually, when I write appeals for others, all that I have to work with is what they happen to remember about their in-network consultations. A few gold nuggets will suffice.
However, once upon a time, my helpee had taped all of his doctor visits. I
requested that he send me the audio files. Then, I settled in at the computer with a bowl of popcorn, and prepared to mine gold nuggets for his appeal.
It was a veritable nugget-fest. If you are going to write an appeal, I would highly recommend paying a visit to the in-network experts that they refer you to. Bring a small recording device, and ask them if you may tape.
In the case where I got to hear the tapes, I was absolutely astonished that the three doctors had agreed to be recorded. They sounded like complete buffoons.
When you consult for the purpose of discrediting, be sure to ask a lot of questions.
If they aren’t getting good outcomes, questions about outcomes will elicit remarks that will be pretty outrageous, and which will look very good in your appeal.
Bring up your expert of choice. That may inspire your in-network specialist to go off the deep end, as in the tapes that my helpee shared with me. He mentioned Dr. Sugarbaker, and the oncologist went on a wild rant:
“That Dr. Sugarbaker! He will take out all your organs, whether you need it or not! He is the most expensive! He is too busy to see you!” And on and on.
I half expected him to say that Dr. Sugarbaker would pull out all of your organs through your nose, do a voodoo dance, and insult your ancestors.
His wacky remarks looked downright nutty, when I quoted him in the appeal.
Ask plenty of probing and provocative questions, tape or write down the in-network doctor’s answers, and showcase his answers in your appeal.
ACME EXPERT REFERS ME TO DR. SUGARBAKER
_____________________________________________________________________________
I explained to Dr. Ward that Dr. Ryan, while undoubtedly a fine surgeon, had no qualifications and little experience with appendix cancer.
Dr. Ward said, “There is a surgeon at the University of Colorado Hospital. I think that he is doing some like Dr. Sugarbaker. His name is Dr. Tom Wilson.”
On 6/18/09, I visited with Dr. Wilson in his office.
Dr. Wilson has less experience than Dr. Ward, doesn’t follow patients.
Dr. Wilson told me that a “debulking” is what I need, followed by chemotherapy administered directly into the closed abdomen. I asked him how many of these surgeries he has performed, and he replied, “Forty-two.” He went on to say that many of the closed perfusions that he has performed have been for other types of cancer—everything from ovarian cancer to mesothelioma.
When I questioned Dr. Wilson about his outcomes, he said, “I’ve only been doing this for five years, so longterm follow-up is limited. Besides, I don’t follow the patients, unless they return with post-surgical complications.”
“Appendiceal neoplasm with peritoneal dissemination could be an indolent disease process. The assessment of any treatment regimen should allow for a minimum of 10 years’ follow-up, and follow-up of twenty years would be ideal.”
(Sugarbaker PH. New standard of care for appendiceal epithelial neoplasms and pseudomyxoma peritonei? The Lancet Oncology 2006; Vol. 7: 73.)
Dr. Wilson does not perform the HIPEC by open perfusion.
Dr. Wilson performs the intraperitoneal chemotherapy by closed perfusion, which has been shown to have zero effect on outcomes. This closed method has been offered for many years, and is considered palliative in nature. Dr. Sugarbaker, on the other hand, is expert at delivering the chemotherapeutic agents by open perfusion, which ensures that they treat every surface of every organ within the abdomen.
Dr. Wilson hates doing these surgeries.
I was not encouraged by Dr. Wilson’s scant experience, lack of qualifications or training for this complex surgery, and his disinterest in following his patients to learn their outcomes.
ACME EXPERT REFERS ME TO DR. SUGARBAKER
Dr. Wilson went on to tell me how much he hates doing these surgeries, as they are very complicated and lengthy, and they seriously cut into his family time.
Dr. Wilson concluded our visit by saying, “I would strongly suggest that you get a second opinion. Dr. Paul Sugarbaker in Washington, D.C. is the world’s expert on this.
Dr. Wilson refuses to do the surgery, admits 14% mortality rate, refers me to Dr. Sugarbaker
On 7/5/09, I called Dr. Wilson’s office to schedule a follow-up meeting per
Dr. Wilson’s suggestion.
I spoke with Dr. Wilson’s patient coordinator, Jan Johnson. Jan said, “Dr. Wilson is not doing these surgeries anymore. He has been questioning his results with these surgeries.”
I was shocked by this turn of events, and sent an email to Dr. Wilson, asking him why he had decided not to do these kinds of surgeries anymore.
Dr. Wilson answered my email with a phone call. He said, “I am not happy with my outcomes … I feel that perhaps my mortality rate is higher than that of other surgeons. I am sorry that I can’t help you.”
Dr. Wilson shared with me that six of his forty-two appendix cancer patients had died—a 14% mortality rate. When I asked him what they had died of, he replied, “Heart attacks or complications from the chemotherapy.” These answers did not inspire confidence.
Dr. Wilson ended our conversation by referring me again to Dr. Sugarbaker; his written referral to Dr. Sugarbaker is attached. (Att. x, Dr. Wilson’s referral.)
This is the in-network Acme specialist to whom I was directed. Not only did he not have any documented good outcomes to offer, but he described a hatred of performing these surgeries, and a complete lack of confidence in performing them without killing the patient. He refused to do the surgery, and referred me to Dr. Sugarbaker.
I know it’s hard to believe, but every word in the “Dr. Wilson” section comes from a real case. I have changed names and locations. However, every word that I have attributed to Dr. Wilson is something this very real doctor said.
When my helpee faxed me the copy of his Bad Medical Story, and I saw his report of the visit with Dr. Wilson, I almost fell off my chair.
He doesn’t follow his patients, he hates doing these surgeries because they cut into his family time, he is not happy with his mortality rate.
The appalling part is not that Dr. Wilson is totally unfit to do this surgery. The appalling part is that, as of today, he has performed forty-two of them. Although he told my helpee that he wasn’t going to do these surgeries anymore, somebody must have told him to start up again.
Last week, one of my neighbors referred a friend of hers to me. The neighbor’s 24-year-old son had just had this same surgery with Dr. Wilson.
The young man’s mother said, “We know that Dr. Wilson is the best.”
“How do you know?” I asked.
“He was recommended,” she replied.
When you are seeking a specialist, I trust that you will choose him based on his qualifications, his experience and, above all, his outcomes.
**********
You find the perfect expert to perform your lifesaving treatment, and your insurer denies, sending you to an in-network doctor instead. Acme Insurance is not sending you there because he has any interest, qualifications, or good results with your treatment-of-choice. They are sending you there because he is contracted with Acme Insurance.
Either visit him or read his resume, learn exactly how unqualified he is. Catch him making all manner of embarrassing remarks. Then, write those remarks down word-for-word, and include them as direct quotes in your appeal.
Next Excerpt 16 “Out-of-Network Expert — Bring in the General”
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