Health Insurance Doesn’t Pay Despite Cancer Screening

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PET/CT exam is covered by statutory health insurance only for certain types of cancer. © Mirco Conrado

At first they are small. Unnoticed, the tumors then develop into malignant cysts. However, if they are detected early, there is a good chance that the cancer can be defeated. Modern technology helps with detection, but its use is costly. Therefore, health insurance companies refuse to cover the cost for all diagnostic procedures. Günter Dieckmann of Bonnen had the same experience – although he was suffering from cancer.

bones (NRW) – The diagnosis struck the 65-year-old like a club. During a check-up last year, his urologist found that he had significantly elevated levels of prostate-specific antigen (PSA). This value may indicate that the man has prostate cancer. It was the same with Günter Dieckmann.

He was operated upon and doctors found a whole series of malignant tumors or metastases. They then removed the entire prostate gland and surrounding tissue, hoping to get rid of anything affected.

The pensioner did not receive radiation or chemotherapy. It didn’t seem necessary. But he was immediately advised to have a check-up every two to three months. The PSA value was checked at each of these appointments – and it continued to rise from time to time. If the prostate is not present it should be zero.

the discovery of the famous needle

Urologists feared that in Dieckmann’s case either new metastases had formed or that not all cancer cells were discovered and removed during the operation. After all, it is no coincidence that the Ancient Greek word metastasis derives from the words “migration” or “transfer”. The discovery of such metastases can therefore be compared to the search for the famous needle in a haystack.

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Fortunately, there are tools that make them easy to track. In Günter Dieckmann’s case, it’s PET/CT. At least that’s what urologists and physicians thought was the safest way to identify hidden metastases. In this test, positron emission tomography (PET), a specialized test method used in nuclear medicine, is combined with computer tomography (CT).

“It is like walking in the dark and there is a forest 100 meters away. Inside is a man who lights up with an LED lamp,” Dieckmann found in an illustrated description. The man with the lamp symbolizes metastasis. In this way the patient is sure whether something new has formed.

Exam pattern not allowed

However, Günter Dieckmann’s health insurance company and medical service did not consider this type of diagnosis necessary. Barmer-Ersatzkasse has refused to charge for the cost. “This is a so-called new test and treatment method. These are methods that have not yet been approved by the competent Federal Joint Committee as a service to be provided by statutory health insurance. They must therefore be provided by statutory health insurance (GKV) or by statutory health insurance (GKV). cannot be taken only under certain conditions,” says a Barmer spokesperson.

The fact that Günter Dieckmann is dissatisfied with this still makes a lot of sense in his company. “Our staff has dealt with the matter thoroughly. Unfortunately, for the given reasons, no other decision is possible,” regrets the Barmer spokesperson. In the United States and many European countries, however, the process has long been recognized and borne by insurance companies. Is.

If Boner had lung cancer, Barmer would have done the same. It also pays for PET/CT diagnostics when lymph node cancer is suspected in children and adolescents. Since none of this applies to him, Dieckmann should not be entitled to assume the costs – the cost plan runs up to around 1500 euros. He still fears for his life.

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Not all criteria met

He has appealed against the decision and attached the letter with immediate recommendations of his urologist and doctors of specialist clinic. The Medical Services (MD) was then the judge in Barmer. Among other things, its specialists must examine whether a 65-year-old has a life-threatening disease, whether there is no recognized treatment for it, or whether there is a possibility of recovery using a “new treatment method.” These are the conditions under which health insurance pays.

However, MD employees came to the conclusion that not all of these criteria were met by Bonner. For example, this applies to the second point. According to expert opinion, there are alternative examination methods, namely CT and/or MRI examination of the pelvis. On the other hand, neither Dieckmann’s urologists nor the physicians attending the specialist clinic thought it made sense. “You can’t see anything in there,” revealed the 65-year-old. “It would be as if the man in the woods hadn’t turned on the light,” he refers to the image above.

On the nine-page argument of disapproval by Barmer and MD, it also states that they only have one cancer stage in four (incurable). The disease is not fatal at the moment. According to the German Cancer Society, prostate cancer is the second deadliest cancer in men, accounting for about 12 percent. However, with early diagnosis, there is a good chance of recovery. This is probably why most private health insurance companies cover the PET/CT exam.

new metastases found

It’s not so quick with Bonner. The operation was performed in the summer of 2021, and doctors are recommending an examination from January. Since then, Dieckmann has struggled to cover the costs. Now he didn’t want to wait any longer. He is in a medical care center near dortmund and paid from my own pocket. Two new metastases were discovered: one in the rectum and one in the fourth lumbar vertebra.

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“They will not show up on exams offered by the health insurance company,” the 65-year-old found. The tragedy: Because the procedure with the health insurance company lasted so long—at least ten months—his specialist feared the tumor had spread further. A grueling cancer therapy now begins for Dieckmann.

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