A Wasted Peer-to-Peer Call for my WellCare Patient

Doris Holt had an unprovoked deep vein thrombosis in her leg. Her managed Medicare plan (ironically called a Medicare Advantage plan – certainly not true for patients who get snuckered into signing up) required a Peer-to-Peer call when I ordered a CT scan of her chest, abdomen and pelvis to look for occult cancer. They teach you to do that in medical school.

The man on the phone called himself doctor so-and-so. He didn’t tell me his specialty.

“Has she had any coags (blood tests for clotting disorders)?”

“No, she needs lifelong anticoagulation with apixiban anyway, so that would be moot.”

“Has she had any other imaging?”

“Doppler of the leg. Mammogram scheduled.”

“Colonoscopy? Pap smear?”

“Colonoscopy consult pending, but she’d have to hold her blood thinner then…”

“Hmmm. Has she had any weight loss or B-symptoms (fever, night sweats etc.).”


“I’m checking her plan.” (Pause.) “I cant approve the chest without a chest X-ray first, or the abdomen-pelvis without a colonoscopy or Pap smear.”

“So, you’re denying everything.”


I didn’t even say goodbye.

Pancreas cancer is first on the CDC’s list of malignancies that can cause blood clots:

Some cancers pose a greater risk for blood clots, including cancers involving the pancreas, stomach, brain, lungs, uterus, ovaries, and kidneys, as well as blood cancers, such as lymphoma and myeloma.

Medicare Advantage is a golden goose for the for-profit insurance companies that offer them. They lure patients in with low premiums (and they get Federal subsidies), hearing aids, free vitamins, rides to the doctor and so on, but they waste my time with roadblocks like peer-to-peer calls and prescription prior authorizations. And they deny rapid diagnosis of occult cancers where time is sometimes of the utmost essence.

The Cruelty of Managed Medicare

5 Responses to “A Wasted Peer-to-Peer Call for my WellCare Patient”

  1. 1 Jean November 7, 2021 at 12:06 am

    I agree wholeheartedly. I despise peer to peer as well as PA for meds because I need a tab versus a capsule or liquid I had to pay cash for a CT with contrast for my husband who needed it for surgical mapping for a large neck schwannoma. Appealed twice, denied twice. Shameful! And mine was a commercial plan.

  2. 3 Deborah VerBeek November 7, 2021 at 4:53 pm

    I see the same thing often. Not even sure it is a medical provider on the phone and he/she certainly hasn’t seen the patient. Will not approve anything that cost $$$. Do not believe that this helps anyone, just causes extreme frustration to always be fighting the system for what is best for our patients.

  3. 4 Ashvin Pandya, MD FAAFP November 10, 2021 at 1:00 pm

    I am disappointed by this MAJOR DISADVANTAGE Of Medicare advantage and similar HMO plans. Can we “ physician organizations “ do anything about it?

  4. 5 Mamadoc November 11, 2021 at 6:32 pm

    Oh for crying out loud. These advantage plans are malignant. They make money (a lot) the way all insurance plans do: by denying care. If you love your parents don’t let them sign up for Medicare advantage plans

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Osler said “Listen to your patient, he is telling you the diagnosis”. Duvefelt says “Listen to your patient, he is telling you what kind of doctor he needs you to be”.



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