March 13, 2010

Getting lots of buzz from the article!

Praise the Lord for how fast He is working in all of this. May the article help others who have chronic pancreatitis learn of the surgery to relieve the pain and may all of us become more aware of our insurances--what's offered and what isn't. Pray for our leaders to do the right thing with our nation's health crisis!

March 10, 2010

Woman Denied Coverage

This article appeared in the Sierra Vista Herald on March 9, 2010

Published on The Sierra Vista Herald (www.svherald.com)

Home > Woman denied coverage for surgery by 2 companies

Woman denied coverage for surgery by 2 companies

Nancy Pitts, right, who is afflicted with chronic pancreatitis, shops at Wal-Mart with her friend Stella McCall. Pitts cannot have surgery yet because her two health insurance companies will not pay for the operation. (Ed Honda•Herald/Review)

Health: Pancreatitis sufferer can't get help she needs

By Dana Cole

Herald/Review

SIERRA VISTA — Nancy Pitts has health insurance. At least, that’s what she thought.

In fact, this 45-year-old has two policies, one with Humana Medicare Advantage and one with University Physicians Healthcare Group, or UPH, both government sponsored programs.

So imagine her frustration when she was denied coverage for a surgical procedure that University Medical Center doctors say could help her find relief from a debilitating, painful condition that has dominated her life for nine years. It’s a new procedure offered at UMC, a type of cell transplant surgery that helps patients who are suffering from chronic pancreatitis.

The auto-islet cell transplant is a surgical procedure that involves removing the patient’s pancreas — the source of the pain — and then relocating the insulin-producing pancreatic islet cells into the liver, where they lodge in blood vessels and release insulin. Because the surgery uses the patient’s own cells, the chance of rejection — which is a big concern in most transplant procedures — is much lower.

The wife of Mark Pitts, who is the senior pastor at Village Meadows Baptist Church, mother of two grown children and a grandmother, Nancy says the excruciating pain she endures on a daily basis is holding her hostage, robbing her of quality time with family and friends.

“My two children were in junior high when I started getting sick in 2001,” she said. “They spent their junior high and high school years watching this.”

Prior to becoming ill, Pitts describes herself as an energetic, active person with lots of motivation. Driven by her passion for children and a desire to teach school, she enrolled at the University of Arizona and graduated with a degree in education in 2001.

“I had to quit a job that I absolutely loved, my dream job, because I couldn’t take the pain any longer,” recalled Pitts, who taught first-grade at Village Meadows Elementary School for a brief time.

Grocery shopping is done with the help of an electric wheelchair, accompanied by a friend or family member. She describes a good day as one where she “gets by with 400 milligrams of pure narcotic painkillers.” On days of full-blown pancreatic attacks, Pitts is completely bed-ridden, despite pain medications. 

“If I’m awake, I’m in pain,” she said. “It’s absolutely exhausting.”

Sick for one year before her problem was diagnosed, Pitts went through multiple hospitalizations, saw a number of specialists and endured several surgeries. She was finally diagnosed in 2002 at UMC by Dr. John Cunningham, a gastroenterologist. While the chronic pancreatitis diagnosis provided Pitts with an explanation for her discomfort, it wasn’t much consolation. At the time Cunningham gave her the news, the only treatment option for chronic pancreatitis was removal of the pancreas, which meant she would be dealing with diabetes for the rest of her life. So Pitts decided against the surgery and continued taking painkillers. 

“In 2005, Dr. Cunningham told me, ‘We’ve done all we can for you. And then he said, there’s no more

hope.’ ” Disappointed, but not defeated, Pitts trudged on. “It certainly wasn’t what I wanted to hear, but I always try to find that silver lining under every dark cloud,” she said. 

So, in September 2009, when she read about a new surgical procedure offered at University Medical Center, a procedure that could help people suffering from chronic pancreatits, Pitts thought that silver lining was in her grasp. 

“University Medical Center is the only hospital in the Southwest that offers this surgery,” she said. “I was ecstatic. I immediately made an appointment to see the doctors there so I could learn more about the procedure. I met Robert Diana, a physician’s assistant who works with the doctors as the surgical coordinator, and the two doctors who are part of the surgical team. They were great.”

Dr. Rainer Gruessner, chairman of the University of Arizona’s department of surgery and chief of surgery at UMC, along with Dr. Horacio Rilo, the director of cellular transplantation, are the two members of the surgical team that Pitts met.

“I went through all the lab tests they required to see if I was a good candidate for the surgery. And when the lab results showed I would be a good candidate, I was really excited.”

But her excitement was short-lived.

When Pitts submitted the paperwork to get the insurance approval process started, she was denied coverage by both insurance companies.  

In addition to the rejections, Pitts says both insurance companies are claiming the other one is the primary coverage provider, so many of her medical bills are going unpaid.

“My medical bills are piling up. It seems the sicker you are, the more you have to fight for coverage, and the more you fight, the sicker it makes you,” she lamented. 

When contacted about coverage questions, Kathleen Oestreich, the CEO of University Physicians Healthcare Group, said that UPH will not be covering the auto-islet cell transplant. It’s because the benefit plan for Healthcare Group is set by the state of Arizona, which authorizes kidney and cornea transplants only. 

“In addition, Humana Medicare Advantage is her (Pitts) primary care provider, not Healthcare Group,” Oestreich indicated. “So this is a Medicare issue, not a UPH issue. Even under Medicare guidelines, there are two types of islet cell transplant procedures, and the one that she is a candidate for is not covered by the federal Medicare program.”

These are rules set by Medicare at the federal level, overseen by the Centers for Medicare and Medicaid Services, Oestreich said. “She (Pitts) is not being singled out. This is a scientific process that ensures best possible coverage for the most people.”

Healthcare Group, which UPH falls under, is a contractor with the state of Arizona. It’s a state-sponsored health coverage program for small business owners and their employees, Oestreich explained. UPH is designed as a limited benefit program, a mechanism to keep health insurance affordable for businesses.

“The program is designed to do the most for the most people,” Oestreich noted. “Every health insurance program has a benefit plan and there’s not one benefit plan out there that covers everything. You have to make decisions that will cover the most people in the most affordable way when you design benefits.”

When contracting to do work for the government, the contractor is obligated to follow state and federal guidelines, she added. 

“Since the procedure that she (Pitts) needs is not a Medicare covered benefit, her plan will not pay for it,” Oestreich said. 

Both of these are government-run programs, supported by taxpayer dollars. UPH is a state program, while Humana Medicare Advantage is a federal

 program.

Calls placed to Medicare regarding its coverage plan were not returned by deadline.

Fundraising campaign

Nancy Pitts, who is suffering from a painful and debilitating condition called chronic pancreatitis, is considered a candidate for a cell transplant surgery by doctors at University Medical Center in Tucson. The surgery provides relief from the severe pain, which doctors describe as intractable. While Pitts has health insurance through two companies, neither plan is authorized to approve the procedure.

When she was advised to consider holding fundraisers to help offset the expense of the surgery, Pitts turned to a transplant advocacy organization, the National Transplant Assistance Fund, or NTAF, for fundraising advice. NTAF is a nonprofit organization that provides expert fundraising guidance to patients, families and communities, while offering fiscal accountability for funds raised. 

Pitts is planning to appeal her case with the two health insurance providers, but is bracing for the daunting task of raising the money she needs for the procedure.

Currently, there is a fundraising campaign on her behalf through NTAF: the “Tribute Gift to NTAF Southwest Islet Cell Transplant Fund in Honor of Nancy Pitts.”

Checks can be made payable to: NTAF Southwest Islet Cell Transplant Fund.

Print in the memo section of the check: In Honor of Nancy Pitts

Send to: NTAF

150 N. Radnor Chester Road, Suite F-120

Radnor PA 19087

Donations can be made online by going to www.ntafund.org [1] and clicking on find patient, and then typing in Nancy Pitts.