CONTACTS 
0203 - CMS Region 9                                                                                                                                                       O-00000877 0605
020301 - Ms. Jullin Kwok; Kaiser Contract Manager                                                                                                                         O-00000877 0605
020303 - 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 35 0000. ref SDS 34 0000.
040502 -
040503 -
040504 -
040505 -
040507 -  ..
0406 -
0407 -
0408 - Background
0409 -
040901 - On 090519 1613 Millie responded, ref SDS 19 8V8H, to the Doctor's
040902 - letter earlier yesterday afternoon on 090519 1536, ref SDS 18 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 19 TY3X,
040905 - and further as planned by the doctor during the meeting on 090515
040906 - 1140. ref SDS 17 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 19 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 19 TX4W
040912 -  ..
040913 - Since Kaiser has delayed ordering treatment, reported on 090520 1710.
040914 - ref SDS 25 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 26
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 26 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 25
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 17 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 28 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 28 HC8O, and the doctor told Millie to call Medicare for
040937 - prescribing treatment to recover from the 8th relapse of cancer.
040938 - ref SDS 28 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 29 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 29 7Z5Y  Millie reports having called
040949 - Kaiser numerous times to speak with the doctor on prescribing
040950 - treatment. ref SDS 29 7Z9Y  Millie notifies medical team she chooses
040951 - hyperthermia and radiation, Doxil, or other agent suitable for
040952 - Millie's patient profile. ref SDS 29 715V
040954 -  ..
040955 - On 090522 1247 Millie received a response from Doctor Johnson to
040956 - Millie's letter on 090522 0813. ref SDS 29 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 30 XO5O
040964 -  ..
040965 - On 090522 1351 Millie responded to Kaiser's letter submitted by Doctor
040966 - Johnson on 090522 1247, ref SDS 30 XO5O, confirming Millie needs
040967 - urgent treatment to start quickly, reported on 090522 1351,
040968 - ref SDS 31 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 31 2T4S  Millie requested advice on treatment with a clinical
040972 - trial at Kaiser, based on patient history, ref SDS 31 2T4V, and
040973 - further requested trade-offs getting more hyperthermia and radiation
040974 - and Doxil or other appropriate agent, including vaccines. ref SDS 31
040975 - 2T4Y
040977 -  ..
040978 - Millie Over-treated Cannot Estimate Time to Progression
040979 - May Not Work at All Millie Over-treated Patient Profile Resists Chemo
040980 - Unfortunately Chemotherapy Drugs Proposed by Kaiser May Not Work at All
040981 - Targeted Treatment Essential Millie's Patient Profile to Recover 8th Relapse
040982 -
040983 - Follow up ref SDS 35 NM6J, ref SDS 33 NV4L. ref SDS 32 NV4L.
040984 -
040985 - On 090522 1953 Millie received a letter from Doctor Johnson responding
040986 - to Millie's letter to the medical team at Kaiser and UCSF this
040987 - afternoon, reported on 090522 1351. ref SDS 31 7R7J  For some reason,
040988 - the doctor he did not submit copies to the medical team, demonstrating
040989 - uneven case management for coordination and collaboration; the doctor
040990 - confirms that treatment with single-agent chemotherapies presented as
040991 - the only choices for care may not work at all for Millie to recover
040992 - from 8th relapse of cancer. ref SDS 32 NV4L
040993 -
040994 -
040996 -  ..
040997 - Demand for Treatment Standard of Care Millie's Patient Profile
040998 -
040999 - On 090523 0148 Millie sent a letter to Paula in the Kaiser Claims
041000 - Resolution Department with copy to medical team demanding treatment to
041001 - recover from 8th relapse applying standard of care for Millie's
041002 - patient profile. ref SDS 33 2P6J
041004 -  ..
041005 - On 090528 0803 called Paula for progress processing Millie's claim for
041006 - treatment with standard of care for Millie's patient profile.
041007 - ref SDS 35 T04L
041008 -
041009 -
041011 -  ..
0411 -
0412 -
0413 - Progress
0414 -
041401 - On 090528 1228 Millie sent a letter to Paula confirming claim
041402 - demanding timely treatment for 8th relapse of cancer. ref SDS 0 UD5H
041403 -
041404 -    1.  Subject: Treatment Plan 8th Relapse of Cancer Kaiser's Standard of Care
041405 -        Date: Thu, 28 May 2009 13:20:29 -0700
041413 -         ..
041414 -    2.  Thanks very much for taking Rod's call this morning [reported
041415 -        on 090528 0803. ref SDS 35 UD5H] in connection with processing
041416 -        my request for Kaiser to prescribe my next treatment [presented
041417 -        in Millie's claim filed with Kaiser Claims Department on 090523
041418 -        0148. ref SDS 33 DQ5S].
041420 -         ..
041421 -    3.  You indicated in the discussion with Rod that Kaiser cannot
041422 -        prescribe my treatment because I have not followed Kaiser's
041423 -        procedures for filing claims [Member Services Claims Resolution
041424 -        sending Millie's claim to Expeditied Claims after Expedited
041425 -        Claims sent the claim to Member Services Claims Resolution, a
041426 -        "loop," reported on 090528 0803, ref SDS 35 PP6Q]
041428 -         ..
041429 -    4.  You also summarized my request for treatment, as a request for
041430 -        treatment in a clinical trial.  That is incorrect. ref SDS 35
041431 -        PX4H
041432 -
041433 -            [On 090601 0818 at 1412 woman from Expedited Claims called
041434 -            and said Kaiser does not understand Millie's claim for
041435 -            standard of care to treat Millie's 8th relapse of cancer in
041436 -            time to be effective. ref SDS 39 TG5G
041438 -             ..
041439 -            [On 090610 0122 notified Paula in Claims Resolution
041440 -            Department that UCSF medical mistakes require UCSF to
041441 -            provide treatment for Millie to recover. ref SDS 40 855G
041443 -             ..
041444 -            [On 090610 0930 Paula advised that UCSF is liable to Kaiser
041445 -            for fixing medical mistakes performing radiation services
041446 -            for Millie on referral from Kaiser. ref SDS 41 855G
041448 -         ..
041449 -    5.  Kaiser can prescribe treatment without a clinical trial, and
041450 -        without waiting for claims documentation to grind through
041451 -        various levels of review that will delay care beyond a point of
041452 -        no return.
041454 -         ..
041455 -    6.  EOC section 2 says in part...
041457 -         ..
041458 -        Your primary care Plan Physician will provide most of your
041459 -        primary care and will help arrange or coordinate other covered
041460 -        Services you get as a Senior Advantage Member (for example,
041461 -        X-rays, laboratory test, theapies, care from Plan Physicians
041462 -        who are specialists, hospital admissions, and follow-up care)
041463 -        [reported in the record on 070927 1311. ref SDS 1 WS6M].
041465 -         ..
041466 -        "Coordinating" your Services includes checking or consulting
041467 -        with other Plan Providers about your care and how it is going.
041468 -        If you need certain types of covered Services, your primary
041469 -        care Plan Physician must prescribe or authorize the Services
041470 -        (for example, some care requires a referral from a Plan
041471 -        Physician for certain types of speciality care). [reported in
041472 -        the record on 070927 1311. ref SDS 1 WT37].
041474 -         ..
041475 -    7.  As noted in my letter to you on 090523 [0148, ref SDS 33 DQ8S],
041476 -        my doctor notified me in a letter on 090521 that I need
041477 -        immediate oncology services because my cancer is progressing
041478 -        [reported on 090521 2006. ref SDS 28 HC8O].  This my 8th
041479 -        relapse, which began on 090331, ref SDS 13 Q64R, I have
041480 -        requested treatment many times, the past 2 months because my
041481 -        doctor advised that my cancer is now very aggressive and so
041482 -        there is a narrowing margin for delay [reported during meeting
041483 -        at Kaiser on 090325 0830. ref SDS 12 P43G].  If I do not get
041484 -        treatment right away, I will be unable to recover.  I realize I
041485 -        may not recovery even with treatment.  Patient history shows
041486 -        that getting the right treatment for my patient profile offers
041487 -        the best chance of longevity with quality of life.
041489 -         ..
041490 -    8.  At this time, Kaiser has not "coordinated," prescribed, nor
041491 -        authorized my treatment.  On 090514 my doctor attempted in good
041492 -        faith to order treatment, as done previously for the past 7
041493 -        relapses.  He was told [by Kaiser management] in this case,
041494 -        when urgent treatment is needed quickly, not to prescribe
041495 -        treatment for me [reported on 090515 1140. ref SDS 17 6575
041497 -         ..
041498 -    9.  My doctor has since discussed prescribing Navelbine, Gemzar,
041499 -        and CPT [cited in Millie's letter on 090522 0813. ref SDS 29
041500 -        7Z6W].  He advised in a letter dated 090522 that these
041501 -        treatments probably will not work for my patient profile
041502 -        [reported on 090522 1953. ref SDS 32 UW6G]; and, he has in fact
041503 -        not prescribed any treatment.
041504 -
041506 -  ..
041507 - Treatments Targeted to Millie's Patient Profile Prevelant in Record
041508 -
041509 -
041510 -   10.  Kaiser has many treatments that can be prescribed which
041511 -        evidence shows will work and comply with standard of care for
041512 -        oncology [listed on 090121 in call from Glenna at UCSF,
041513 -        ref SDS 5 EV53].  Some protocols involve clinical trials and
041514 -        others do not, and so involve composite modalities with
041515 -        elements of non-clinical trials and elements of  clinical
041516 -        trials.  These are decisions for my doctor.
041518 -         ..
041519 -   11.  I completed a regimen ordered by my doctor on referral to UCSF
041520 -        of radiation and hyperthermia on 090317. ref SDS 11 9L7K  There
041521 -        was no clinical trial involved [see Kaiser referral on 090205
041522 -        1426. ref SDS 7 278T, and radiation treatment plan received on
041523 -        090226 1342, ref SDS 9 D452].  On 090312 examination showed
041524 -        this was effective. ref SDS 10 YX9F  On 090325 Doctor Johnson my
041525 -        primary care physician made an examination and advised this
041526 -        treatment was very effective. ref SDS 12 P369  [On 090331
041527 -        Doctor Rugo reported in a letter that treatment with radiation
041528 -        and hyperthermia is very effective, reported on 090401 0121.
041529 -        ref SDS 14 K56O]  On 090423 Doctor Hsu, who performed radiation
041530 -        and hyperthermia, examined me and advised the treatment was
041531 -        very effective. ref SDS 15 YN5N
041533 -         ..
041534 -   12.  Doctor Hsu advised on 090423 that best practice would be to
041535 -        treat my condition with systemic care. ref SDS 15 UG5L
041536 -        Previously on 090129, Doctor Rugo prescribed systemic care in
041537 -        combination with Doxil and hyperthermia [reported on 090130
041538 -        1722. ref SDS 6 TZ6H].  This is not a clinical trial.  Kaiser
041539 -        approved this treatment in a referral on 090202 [received in
041540 -        the record on 090205 1426. ref SDS 7 278T].  On 090514 Doctor
041541 -        Rugo notified Kaiser that best evidence shows I could also be
041542 -        treated in a clinical trial, ref SDS 16 D647; Doctor Rugo sent
041543 -        a letter to Kaiser recommending the best course of treatment
041544 -        would be with MPA in a clinical trial. ref SDS 16 DI63].  At
041545 -        that time, Doctor Rugo also advised I could be treated with
041546 -        bevacizumab, which would not require a clinical trial.
041547 -        ref SDS 16 CZ7J
041549 -         ..
041550 -   13.  This record indicates Kaiser has many treatments to prescribe
041551 -        and authorize treatment exercising responsibility for my care
041552 -        based on best evidence of what will work for my patient
041553 -        profile.
041554 -
041555 -            [On 090610 0122 notified Paula in Claims Resolution
041556 -            Department that UCSF medical mistakes require UCSF to
041557 -            provide treatment for Millie to recover. ref SDS 40 855G
041559 -             ..
041560 -            [On 090610 0930 Paula advised that UCSF is liable to Kaiser
041561 -            for fixing medical mistakes performing radiation services
041562 -            for Millie on referral from Kaiser. ref SDS 41 855G
041564 -         ..
041565 -   14.  I do not wish to be a burden for my doctor, nor the many
041566 -        excellent people at Kaiser who have enabled me to survive far
041567 -        beyond the normal trajectory for my disease, reported by Doctor
041568 -        Johnson on 090325. ref SDS 12 P39M
041570 -         ..
041571 -   15.  I believe Kaiser is mistaken failing to continue an excellent
041572 -        record prescribing my care [reported during meeting with Doctor
041573 -        Johnson on 090213 1140, ref SDS 8 ES7I].  I am concerned that
041574 -        waiting for Kaiser's review process, as you outlined today
041575 -        [Claims Resolution sending the case to Expedited Claims, after
041576 -        Expedited Cliams had sent the matter to Claims Resolution, and
041577 -        taking 5 - 10 days to fill out a form, reported on 090528 0803.
041578 -        ref SDS 35 X74F] will cause my cancer to cascade out of
041579 -        control, such that any solution will come too late to be
041580 -        effective.
041581 -
041583 -  ..
041584 - Mitigate Damages Millie Offers to Drive to Kaiser's Office for Form
041585 - Authorization for Representation Millie Will Drive to Kaiser's Office
041586 -
041587 - Follow up ref SDS 35 4V5I.
041588 -
041589 -   16.  You said in the call with Rod today that Kaiser requires me to
041590 -        sign another document which has been put in the mail in order
041591 -        for me to have professional assistance for case management
041592 -        [reported on 090528 0803. ref SDS 35 4V5I], in the same way
041593 -        that Doctor Johnson provides medical advice.  In order to
041594 -        mitigate delays, please let me know where to go, and I will
041595 -        drive this afternoon to that location and sign documents Kaiser
041596 -        needs for me to have assistance performing Kaiser's review
041597 -        procedures.
041598 -
041599 -            [On 090601 0818 Millie received authorization form from
041600 -            Kaiser in the mail; she signed and faxed the form to
041601 -            Kaiser. ref SDS 39 UD5H
041603 -         ..
041604 -   17.  You know from your call on 071006 that I am emotionally unable
041605 -        to conduct calls with Kaiser's professional claims adjusters,
041606 -        like you, about complex case management issues. ref SDS 2 ZE9H
041608 -         ..
041609 -   18.  You asked not to get any more email [reported on 090528 0803,
041610 -        ref SDS 35 T16G].
041612 -         ..
041613 -   19.  At this time, email is my only means of assisting Kaiser in
041614 -        prescribing my treatment [Millie's letter on 090520 reporting
041615 -        that Doctor Johnson, her primary care physician, does not have
041616 -        time to return many calls over several days, ref SDS 25 ZF5R,
041617 -        and beginning on 090519, ref SDS 19 TY4W; additionally, on
041618 -        090521, Expedited Claims Department notified Millie that her
041619 -        case had been referred to Paula's office in the Claims
041620 -        Resolution Dpartment. ref SDS 27 UD5H]
041621 -
041623 -  ..
041624 - Kaiser Failure to Perform Requires Billing Kaisre for Alternative Care
041625 - Millie Notifies Kaiser Failure to Perform Forces Millie to Get Care
041626 - IBC Progressing Needs Immediate Treatment Cannot Wait for Admin Delays
041627 -
041628 -
041629 -   20.  My feeling today from observing spread of IBC on my arm [is]
041630 -        that progression of my disease will not wait for further delay
041631 -        in delivery of treatment.  I could be mistaken, but I do have
041632 -        professional advise at this time.  Therefore, I am very
041633 -        concerned that if Kaiser later prescribes treatment in several
041634 -        weeks, that may be too late to be effective.
041636 -         ..
041637 -   21.  To mitigate damages from delayed care, I can go to UCSF and ask
041638 -        Doctor Rugo and Doctor Hsu to prescribe treatment.  I would ask
041639 -        UCSF to bill Kaiser for this oncololgy service under EOC
041640 -        section 2 [cited above, ref SDS 0 4N3X, and reported on 070927
041641 -        1311, ref SDS 1 WS6M].  If I am billed, I would then have time
041642 -        to go through Kaiser's claim review process, as we did in 2007
041643 -        [beginning with Paula's call on 071006 1539, ref SDS 2 0001].
041645 -         ..
041646 -   22.  I will submit to Kaiser UCSF's recommended treatment plan as
041647 -        best evidence of care for my patient profile.  If Kaiser does
041648 -        not authorize treatment, I will sign UCSF's documents to be
041649 -        responsible for costs, and will seek recovery from Kaiser.
041650 -
041651 -            [On 090528 1334 Millie requested medical services from
041652 -            UCSF and notified UCSF and Kaiser that Kaiser is liable
041653 -            for costs, as a consequence of failure to perform
041654 -            insurance requirements. ref SDS 36 2L7P
041656 -             ..
041657 -            [On 090528 1613 Doctor Rugo prescribes a new treatment
041658 -            starting next week with gemcitabine at Kaiser.
041659 -            ref SDS 37 XZ4M
041661 -             ..
041662 -            [On 090528 1652 Millie responded to Doctor Rugo's letter
041663 -            notifying medical team again that she needs a
041664 -            prescription to recover from the 8th relapse of cancer,
041665 -            and asking for comparison of the new treatment proposed
041666 -            by Doctor Rugo with other treatments the team has
041667 -            presented. ref SDS 38 MZ7N
041669 -             ..
041670 -            [On 090610 0122 notified Paula in Claims Resolution
041671 -            Department that UCSF medical mistakes require UCSF to
041672 -            provide treatment for Millie to recover. ref SDS 40 855G
041674 -             ..
041675 -            [On 090610 0930 Paula advised that UCSF is liable to Kaiser
041676 -            for fixing medical mistakes performing radiation services
041677 -            for Millie on referral from Kaiser. ref SDS 41 855G
041679 -         ..
041680 -   23.  I am open to other procedures to mitigate damages in this case.
041681 -        Please let me know if there is another way for Kaiser to
041682 -        prescribe my treatment in time to be effective for my patient
041683 -        profile?
041684 -
041685 -            [On 090601 0818 at 1132 Brad in the Oncology Pharmacy
041686 -            Department at Kaiser called and reported that Doctor
041687 -            Johnson issued a Chemotherapy Order for Kaiser to treat
041688 -            Millie with Gemzare. ref SDS 39 PQ7V  The order was
041689 -            unsigned and so treatment could not be scheduled, because
041690 -            the doctor went home with a headache. ref SDS 39 PQ4F  Brad
041691 -            explained Gemzar side effects that are not appropriate for
041692 -            Millie's patient profile, because it presents significant
041693 -            risks of infection and death. ref SDS 39 8J8L
041695 -         ..
041696 -   24.  I emphasize that I remain very grateful to my doctor, and all
041697 -        of the people at Kaiser who have done great work providing my
041698 -        health care the past 8 years.
041700 -         ..
041701 -   25.  This is a very complex medical challenge to care for patients
041702 -        who exceed disease trajectory by a wide margin [cited by Doctor
041703 -        Johnson, primary care physician, during meeting at Kaiser on
041704 -        090325 0830. ref SDS 12 P39M].  Are clinical trials a critical
041705 -        component for oncology standard of care, as demonstrated by my
041706 -        patient history [reported on 090213 1140, ref SDS 8 ES7I].  Can
041707 -        EOC section 7 expand patient choices to seek care outside of
041708 -        Kaiser, while Kaiser retains responsibility to prescribe
041709 -        standard of care?  I hope we can be constructive and
041710 -        professional while struggling to find a reasoned solution.
041711 -
041712 -            [On 090610 0122 notified Paula in Claims Resolution
041713 -            Department that UCSF medical mistakes require UCSF to
041714 -            provide treatment for Millie to recover. ref SDS 40 855G
041716 -             ..
041717 -            [On 090610 0930 Paula advised that UCSF is liable to Kaiser
041718 -            for fixing medical mistakes performing radiation services
041719 -            for Millie on referral from Kaiser. ref SDS 41 855G
041720 -
041726 -
041727 -
041728 -
041729 -
041730 -
041731 -
041732 -
041733 -
041734 -
041735 -
041736 -
0418 -