THE WELCH COMPANY
440 Davis Court #1602
San Francisco, CA 94111-2496
415 781 5700
rodwelch@pacbell.net


S U M M A R Y


DIARY: May 23, 2009 01:48 AM Saturday; Rod Welch

Millie asks Kaiser Claims Department for treatment 8th relapse of cancer.

1...Summary/Objective
2...Millie Over-treated Cannot Estimate Time to Progression
3...May Not Work at All Millie Over-treated Patient Profile Resists Chemo
4...Unfortunately Chemotherapy Drugs Proposed by Kaiser May Not Work at All
5...Targeted Treatment Essential Millie's Patient Profile to Recover 8th Relapse


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CONTACTS 
0206 - CMS Region 9                                                                                                                                                       O-00000877 0605
020601 - Ms. Jullin Kwok; Kaiser Contract Manager                                                                                                                         O-00000877 0605
020603 - Kaiser Medicare Contract                                                                                                                                         O-00000877 0605

SUBJECTS
Default Null Subject Account for Blank Record

0403 -
0403 -    ..
0404 - Summary/Objective
0405 -
040501 - Follow up ref SDS 50 0000. ref SDS 49 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Progress
0409 -
040901 - On 090519 1613 Millie responded, ref SDS 38 8V8H, to the Doctor's
040902 - letter earlier yesterday afternoon on 090519 1536, ref SDS 37 5K7H;
040903 - and, Millie asks the doctor to prescribe treatment so she can recover
040904 - from cancer, as done previously in patient history, ref SDS 38 TY3X,
040905 - and further as planned by the doctor during the meeting on 090515
040906 - 1140. ref SDS 36 655R  Millie also asked the doctor to call on
040907 - expediting treatment in time to be effective, see again on 090520
040908 - 1613, ref SDS 38 TY4W; and Millie asks Doctor Rugo for a "drop dead"
040909 - date on how soon treatment must start in order to be effective, also,
040910 - reported on 090519 1613. ref SDS 38 TX4W
040912 -  ..
040913 - Since Kaiser has delayed ordering treatment, reported on 090520 1710.
040914 - ref SDS 43 ZF4Q, then on 090521 0211 Millie's letter to Doctor Rugo at
040915 - UCSF with copy to Doctor Hsu asks about getting treatment with
040916 - hyperthermia and Doxil, while Kaiser resolves delays ordering MPA
040917 - prescribed by Doctor Rugo for Millie to recover from 8th relapse of
040918 - cancer, which Millie reports is getting worse every day, ref SDS 44
040919 - FM7Q, and since Kaiser has previosuly authorized treatment with
040920 - hyperthermia and Doxil, which Doctor Rugo recommended earlier on
040921 - 090129 for Millie to recover from the 7th relapse. ref SDS 44 6M4F
040923 -  ..
040924 - On 090521 2006, Millie received a letter from Doctor Johnson
040925 - responding to Millie's letter to the medical team on 090520 1710, and
040926 - requesting that Kaiser prescribe treatment suitable for Millie's
040927 - patient profile for recovering from 8th relapse of cancer. ref SDS 43
040928 - P65H   Doctor Johnson's letter was sent through Kaiser's Knowledge
040929 - Management System and so was not disclosed to the medical team, and it
040930 - did transmit the Doctor Johnson's medical chart for the meeting on
040931 - 090515, ref SDS 35 YT5N, and said that Millie could "choose" any
040932 - treatment she wants, and no treatment is superior for Millie's patient
040933 - profile, 090521 2006, ref SDS 46 9Q9H; the doctor noted Millie's
040934 - cancer is progressing and so she needs to start treatment by the end
040935 - of the week, which was in just 12 hours, which means today,
040936 - ref SDS 46 HC8O, and the doctor told Millie to call Medicare for
040937 - prescribing treatment to recover from the 8th relapse of cancer.
040938 - ref SDS 46 HC93
040940 -  ..
040941 - On 090522 0813 Millie responded to Doctor Johnson's letter on 090521
040942 - 2006 and submitted copies to the medical team to maintain
040943 - collaboration that has been effective treating Millie the past 8
040944 - years.  Millie also sent a copy to Jullian Kwok to notify Medicare
040945 - that Kaiser is refusing treatment. ref SDS 47 RX6L  Millie asked
040946 - Kaiser to prepare a workup and Tumor Board to evaluate Millie's next
040947 - treatment, including trade-offs comparing all of the treatments
040948 - available for Millie. ref SDS 47 7Z5Y  Millie reports having called
040949 - Kaiser numerous times to speak with the doctor on prescribing
040950 - treatment. ref SDS 47 7Z9Y  Millie notifies medical team she chooses
040951 - hyperthermia and radiation, Doxil, or other agent suitable for
040952 - Millie's patient profile. ref SDS 47 715V
040954 -  ..
040955 - On 090522 1247 Millie received a response from Doctor Johnson to
040956 - Millie's letter on 090522 0813. ref SDS 47 RX6L who sent copies to the
040957 - medical team, and saying Kaiser has performed workups, but does not
040958 - submit any works, and says Millie's patient profile is too complex for
040959 - Tumor Board to evaluate best course of treatment, and that Millie's
040960 - patient profile resists single agent treatments like Gemzar and
040961 - Navelbine, and that Millie can choose Hospice instead of treatment
040962 - with drugs which her patient profile now resists. ref SDS 48 XO5O
040964 -  ..
040965 - On 090522 1351 Millie responded to Kaiser's letter submitted by Doctor
040966 - Johnson on 090522 1247, ref SDS 48 XO5O, confirming Millie needs
040967 - urgent treatment to start quickly, reported on 090522 1351,
040968 - ref SDS 49 7R7J; Millie asks if treatment with Gemzar and Navelbine
040969 - will be weeks of agony then progression of cancer that requires
040970 - another treatment "targeted" to treat Millie's patient profile.
040971 - ref SDS 49 2T4S  Millie requested advice on treatment with a clinical
040972 - trial at Kaiser, based on patient history, ref SDS 49 2T4V, and
040973 - further requested trade-offs getting more hyperthermia and radiation
040974 - and Doxil or other appropriate agent, including vaccines. ref SDS 49
040975 - 2T4Y
040976 -
040978 -  ..
040979 - Millie Over-treated Cannot Estimate Time to Progression
040980 - May Not Work at All Millie Over-treated Patient Profile Resists Chemo
040981 - Unfortunately Chemotherapy Drugs Proposed by Kaiser May Not Work at All
040982 - Targeted Treatment Essential Millie's Patient Profile to Recover 8th Relapse
040983 -
040984 - Follow up ref SDS 50 NV4L.
040985 -
040986 - On 090522 1953 Millie received a letter from Doctor Johnson responding
040987 - to Millie's letter to the medical team at Kaiser and UCSF this
040988 - afternoon, reported on 090522 1351. ref SDS 49 7R7J  For some reason,
040989 - the doctor he did not submit copies to the medical team, demonstrating
040990 - uneven case management for coordination and collaboration; the doctor
040991 - confirms that treatment with single-agent chemotherapies presented as
040992 - the only choices for care may not work at all for Millie to recover
040993 - from 8th relapse of cancer. ref SDS 50 NV4L
040995 -  ..
040996 - On 090523 0148 Millie presented a demand to Kaiser Claims Department
040997 - with copy to medical team for treatment to recover from 8th relapse
040998 - applying standard of care for Millie's patient profile. ref SDS 0 2P6J
040999 -
041000 -    1.  Subject: Treatment Plan 8th Relapse of Cancer Kaiser's Standard of Care
041001 -        Date: Sat, 23 May 2009 02:19:34 -0700
041012 -         ..
041013 -    2.  You are familiar with my care at Kaiser based on your letter to
041014 -        Rod dated 071130, confirming notice in your call a few days
041015 -        earlier on 071128 that sets out requirements for case
041016 -        management of my care at Kaiser authorizing payment to UCSF for
041017 -        treatment in clinical trials. ref SDS 15 TH8L
041019 -         ..
041020 -    3.  You have received correspondence the past few days on immediate
041021 -        need for treatment of my 8th relapse of cancer, ref SDS 0 UD5H,
041022 -        which I summarize...
041023 -
041024 -            [On 090528 0803 Kaiser has not responded; called and talked
041025 -            to Paula; she sent this letter today demanding care for
041026 -            cancer to Kaiser's Expedited Claims Department, ref SDS 51
041027 -            PP6Q, which has already reviewed the matter an advised that
041028 -            Expedited Claims sent Millie's case to Paula's Department
041029 -            in Kaiser Member Services Claims Resolution, reported on
041030 -            090521 0902. ref SDS 45 RW82
041032 -         ..
041033 -    4.  At your request, Rod talked to Expedited Claims on Wednesday,
041034 -        090520, and requested a doctor's order to treat my 8th relapse
041035 -        of cancer [using standard of care for my patient profile,
041036 -        listed in the record meeting Doctor Johnson at Kaiser on 090213
041037 -        1140. ref SDS 23 ES7I, and as required by insurance EOC Section
041038 -        2, reported on 090520 1203, ref SDS 42 ER4F].  The next day on
041039 -        090521, EC called and said my claim is not denied, and that
041040 -        Member Services [Claims Department, Paula's office] would be
041041 -        asked to assist my doctor in prescribing my next treatment
041042 -        [reported on 090521 0902. ref SDS 45 UD5H]
041044 -         ..
041045 -    5.  I then received a letter from Doctor Johnson later that day on
041046 -        090521 saying in part...
041048 -         ..
041049 -        "You can choose which next treatment regimen that you want.  At
041050 -        this time, no treatment would be considered more superior than
041051 -        another" [reported on 090521 2006, ref SDS 46 9Q9H].
041053 -         ..
041054 -    6.  I object to this procedure as conflicting with standard of care
041055 -        for oncology.  Apart from Kaiser presenting no treatments to
041056 -        "choose," at no time have I ever been asked nor required to
041057 -        "choose" a treatment; at all times I have relied on my doctor
041058 -        to diagnose and prescribe treatment supported by best evidence
041059 -        within Kaiser's standard of care for oncology.  On 040318 I
041060 -        suffered the first relapse of cancer.  My doctor ordered
041061 -        treatment in a clinical trial as my best course of treatment
041062 -        for standard of care [reported on 040318 1615, ref SDS 1 YO7H].
041064 -         ..
041065 -    7.  This same scenario occurred again on 041210, ref SDS 5 CF9F;
041066 -        and it occurred again when my doctor prescribed treatment in a
041067 -        clinical trial on 070105. ref SDS 12 PK7L
041069 -         ..
041070 -    8.  On this last prescription, you became involved and issued the
041071 -        letter on 071130 [received in the record on 071204 1517,
041072 -        ref SDS 16 TH8L], which has sustained my care the past 3 years
041073 -        at UCSF under Doctor Johnson's supervision at Kaiser.
041075 -         ..
041076 -    9.  As you can see from Doctor Johnson's letter yesterday, Kaiser
041077 -        has not prescribed treatment [reported on 090522 1953,
041078 -        ref SDS 50 NV4L].  He says the best evidence indicates
041079 -        treatments he has at Kaiser may not work at all. ref SDS 50
041080 -        UW6G
041082 -         ..
041083 -   10.  This problem was solved on 040318, by Doctor Johnson
041084 -        prescribing my treatment in a clinical trial as "standard of
041085 -        care" for oncology.  It was solved again on 041210, and on
041086 -        070105 [see case study showing Kaiser prescribing Millie's
041087 -        treatment in clinical trials. 090522 1247, ref SDS 48 4Q88].
041089 -         ..
041090 -   11.  Doctor Johnson told me on Thursday that I need urgent treatment
041091 -        quickly [reported on 090521 2006. ref SDS 46 HC8O  However, I
041092 -        do not have a prescription.
041094 -         ..
041095 -   12.  I have been requesting treatment for the past month, because on
041096 -        090331 Doctor Hsu at UCSF said I likely have relapsed with IBC
041097 -        again [reported in the record on 090401 0032. ref SDS 30 R24X],
041098 -        which was confirmed by Doctor Rugo at UCSF on 090514 0830.
041099 -        ref SDS 34 5U4M, and further by Doctor Johnson at Kaiser the
041100 -        next day on 090515 1140. ref SDS 35 D452  Earlier on 090213
041101 -        Doctor Johnson explained that my good fortune to have survived
041102 -        through 8 relapses with excellent care from Kaiser has narrowed
041103 -        the margin for error and delay starting my treatment.
041104 -        ref SDS 23 PL5K
041105 -
041106 -            [On 090528 0803 Kaiser has not responded; called and talked
041107 -            to Paula; she sent this letter today demanding care for
041108 -            cancer to Kaiser's Expedited Claims Department, ref SDS 51
041109 -            PP6Q, which has already reviewed the matter an advised that
041110 -            Expedited Claims sent Millie's case to Paula's Department
041111 -            in Kaiser Member Services Claims Resolution, reported on
041112 -            090521 0902. ref SDS 45 RW82
041114 -             ..
041115 -            [On 090528 1228 Kaiser failed to perform requirements to
041116 -            provide care; Millie notifies Kaiser she will get treatment
041117 -            and bill Kaiser, as prescribed by insurance agreement.
041118 -            ref SDS 52 4N4S
041120 -             ..
041121 -            [On 090528 1613 Doctor Rugo prescribes a new treatment
041122 -            starting next week with gemcitabine at Kaiser.
041123 -            ref SDS 53 XZ4M
041125 -             ..
041126 -            [On 090528 1652 Millie responded to Doctor Rugo's letter
041127 -            notifying medical team again that she needs a
041128 -            prescription to recover from the 8th relapse of cancer,
041129 -            and asking for comparison of the new treatment proposed
041130 -            by Doctor Rugo with other treatments the team has
041131 -            presented. ref SDS 54 MZ7N
041133 -         ..
041134 -   13.  I am therefore requesting Kaiser's deference to doctor
041135 -        discretion for medical necessity, because I need a call with my
041136 -        next appointment to get treatment implementing Kaiser's
041137 -        standard of care for oncology using clinical trials to expand
041138 -        treatments, since my doctor says in his letter yesterday that
041139 -        treatments at Kaiser won't work for me [reported on 090522
041140 -        1953, ref SDS 50 UW6G].
041141 -
041142 -            [On 090528 0803 Kaiser has not responded; called and talked
041143 -            to Paula; she sent this letter today demanding care for
041144 -            cancer to Kaiser's Expedited Claims Department, ref SDS 51
041145 -            PP6Q, which has already reviewed the matter an advised that
041146 -            Expedited Claims sent Millie's case to Paula's Department
041147 -            in Kaiser Member Services Claims Resolution, reported on
041148 -            090521 0902. ref SDS 45 RW82
041150 -         ..
041151 -   14.  Doctor Rugo and Doctor Hsu at UCSF need support from Kaiser to
041152 -        continue their excellent care collaborating with Doctor
041153 -        Johnson, as my primary care physician.
041155 -         ..
041156 -   15.  Please issue another letter extending your letter on 071130 so
041157 -        that my doctor can order treatment using clinical trials to
041158 -        continue implementing Kaiser's standard of care for oncology,
041159 -        as Kaiser has done the past 5 years in my case.
041160 -
041166 -
041167 -
041168 -
041169 -
041170 -
041171 -
041172 -
041173 -
041174 -
041175 -
041176 -
041177 -
0412 -