Melanoma and My Medical

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I had the pleasure of being diagnosed with a melanoma (on my thigh) in January. I’m a student pilot and am about half way or so toward getting my certificate.

The initial pathology showed the melanoma was unulcerated and had a depth of 1.1mm. I had surgery for a wide area excision and sentinel node biopsy. The pathology on the missing chunk of my leg and lymph nodes was clear. Good news for me, but bad news for my flying I think.

I understand that the melanoma diagnosis means I’m immediately grounded as PIC (but I may receive dual instruction).

The FAA website seems to say that I can get my medical back by receiving a Special Issuance from the AMCD or RFS. The FAA website directs the AME to defer and “submit all pertinent medical records, operative/pathology reports, and current oncological status report, and current MRI of the brain” to the AMCD or RFS.

Other unofficial websites say that, after the Special Issuance, I will have to get a new MRI and go to the AME every year for 5 years.

The bummer about this is that I don’t think the MRI is medically necessary, which means I will be paying out of pocket for the MRI rather than through insurance. I will ask my oncologist if she will order the MRI, but I am not hopeful. Although I haven’t called around yet, a radiologist friend tells me that an MRI of the brain runs about $1,500.

Lots of questions:

- How do I go about getting the Special Issuance? Do I just gather up the relevant documentation, make an appointment with my AME, fill out a FAA Form 8500-8, and bring my documents along to the appointment?

- Do the medical reports need to be specifically addressed to the FAA, or can it just be a generic report?

- For the MRI, do I just need to provide the FAA with the film or the report? Or both?

- Should I ask the AME to submit to the AMCD or RFS? Does it matter?

- Will I really have to jump through these (expensive) hoops every year for 5 years?

- At this point, I still have the option of forgetting the medical and going the no medical/light sport route, right?

- If I initially get the Special Issuance, but later let it lapse by not getting the annual MRIs, can I still use the no medical/light sport option?

Any input/advice is greatly appreciated. Thanks.
 
Bruce Chien will be back online to reply to some of these recent posts soon I imagine. Until then keep flying w/ a CFI and wait to follow thru on the medical pending Bruce's recommendations.
 
Yes you will need the MRI, this year and every year or 5 years. The problem is that about 40% of these will present with a brain metastasis when they re-present again (Nodes neg, > 0.75 breslow depth, or > clarke level 5 melanoma). This really falls off after the 3rd year, and by year 5 they can cut you loose.

Since the rate of finding something in your situation is small, but the therapy changes if the Brain is positive, make CERTAIN your Oncologist knows you understand this point. She will find it very hard to not order the MRI given the power of the attorneys on this particular point. Then you may face an ins. company denial- their attorneys keep trying to show the company that they are worth their 200K salaries.

If you had a presentation beyond the node, a 3 year disease free break is required- rescanned brain to pelvis at the 3 year break. I am currently supporting a Chicago part 121 aviator who is getting scanned every 4 months- Brain, Chest and Abdomen, and wants to return to the flight deck.

IF you let it lapse and go LSA, that is NOT a denial. That is a lapsing. That is okay.
 
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IF you let it lapse and go LSA, that is NOT a denial. That is a lapsing. That is okay.
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Good advice from Dr. Bruce. The other route is filled with hassle.
 
bbchien said:
Yes you will need the MRI, this year and every year or 5 years. The problem is that about 40% of these will present with a brain metastasis when they re-present again (Nodes neg, > 0.75 breslow depth, or > clarke level 5 melanoma). This really falls off after the 3rd year, and by year 5 they can cut you loose.

Since the rate of finding something in your situation is small, but the therapy changes if the Brain is positive, make CERTAIN your Oncologist knows you understand this point. She will find it very hard to not order the MRI given the power of the attorneys on this particular point. Then you may face an ins. company denial- their attorneys keep trying to show the company that they are worth their 200K salaries.

If you had a presentation beyond the node, a 3 year disease free break is required- rescanned brain to pelvis at the 3 year break. I am currently supporting a Chicago part 121 aviator who is getting scanned every 4 months- Brain, Chest and Abdomen, and wants to return to the flight deck.

IF you let it lapse and go LSA, that is NOT a denial. That is a lapsing. That is okay.
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So, if he goes through all this, and gets a Denial from the FAA on the Medical / SI / of this one or any of the future check-ins that occur for the next 5 years, that kills the LSA Option then doesn't it? Also, does that stop the chance of Glider Flying?
 
Rob Schaffer said:
So, if he goes through all this, and gets a Denial from the FAA on the Medical / SI / of this one or any of the future check-ins that occur for the next 5 years, that kills the LSA Option then doesn't it? Also, does that stop the chance of Glider Flying?
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Yes (Sport Pilot other than glider or balloon) and no (glider).
61.23 b

But in any case - medical or not...
"Not know or have reason to know of any medical condition that would make that person unable to operate a light-sport aircraft in a safe manner"

But you knew that.
 
Capt. Geoffrey Thorpe said:
Yes (Sport Pilot other than glider or balloon) and no (glider).
61.23 b

But in any case - medical or not...
"Not know or have reason to know of any medical condition that would make that person unable to operate a light-sport aircraft in a safe manner"

But you knew that.
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I do not believe that a diagnosis of melanoma is automatically a "medical condition that would make that person unable to operate a light-sport aircraft in a safe manner". If the person had a recent negative brain MRI and no evidence of distant metastasis then I do not believe that it would be disqualifying for light sport even though it could be disqualifying for a 3rd class medical. Perhaps Dr. Bruce will weigh in.
 
Given the propensity of melanoma to metastasize to the brain, and its rapid and invasive growth thereafter, I would self-ground until I was really, really certain I had no metastases. Melanoma is tough.
 
steingar said:
Given the propensity of melanoma to metastasize to the brain, and its rapid and invasive growth thereafter, I would self-ground until I was really, really certain I had no metastases. Melanoma is tough.
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It depends on initial staging and how recent the MRI of the brain or PET scan. I would defer to an oncologist but suspect that 6 to 12 months is adequate MRI interval to exclude significant brain metastasis if there is no other evidence of metastasis at that time. It might be possible to stagger PET and MRI so that insurance will cover these since there is probably a minimum time interval for reimbursement. Median/mean doubling time for primary melanoma is 94/144 days. I would be willing to shell out an extra $1,500 to $2,000 periodically for a brain MRI to be able to keep flying light sport.
 
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I think the real key on something like this as it relates to your FAA medical is to retain someone like Bruce to work WITH you toward getting your medical back. It is a convoluted process and a misstep can set you back a lot of time in regaining the medical so IMHO it would be worth it to have someone with intimate knowlege of the process say ok now step 1 Do sucha and such. Ok Now Step to get this scan, Ok new step 3 get this test.

Obviously your FIRST concern is your Physical health and you do what you have to do to survive but when thankfully you are past that stage I think you need an advisor and advocate.
 
Hopefully, the appropriate medical specialist will work with the AME to determine if it is safe to fly anything and what would be needed to obtain a special issuance.
 
- With a confirmed tissue diagnosis of melanoma, your oncologist should have no problem justifying an annual brain MRI. Depending on your insurance plan, they may have to be pre-certified by the insurance company, persistence on the side of the doc pays off here.

- If 'A' doesn't work, make sure you get a 'severe headache h/o of melanoma' at least once a year and get the PA at the urgentcare to order an MRI on you. It's only fraud if someone can proove that you didn't have a headache:fcross:.

- If you are indeed faced with a situation where you have to pay for the MRI out of pocket, go shop around. Dont just go to the hospital or the oncologist owned MRI facilty she sends you to. Currently, there is a contraction in the imaging center market, cash up front can get you the study at or below insurance rates if you are aggressive about it.
 
While reviewing grants for a major philanthropist I saw the actual hospital cost for an MRI. It was in the hundreds.
 
OP here . . .

Thanks, to Dr. Bruce and everyone else for their input.

I think right now, I'm inclined to get the first MRI (reimbursed by insurance or not), get my medical back, and complete my PP training. From there, I'll just figure it out as it comes.

Thanks again to everyone.

steingar said:
Given the propensity of melanoma to metastasize to the brain, and its rapid and invasive growth thereafter, I would self-ground until I was really, really certain I had no metastases. Melanoma is tough.
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Hey, I'm not dead yet! LOL
 
to the OP..

Hang in there, take care of your health first. Plenty of time to fly once your squared away.

+1 for working with Dr. Bruce.......he is the master!
 
steingar said:
While reviewing grants for a major philanthropist I saw the actual hospital cost for an MRI. It was in the hundreds.
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'Cost' in a MRI is difficult to calculate. What do you factor in ? Capital expense for the magnet, maintenance contract, helium bill, staff expenses for technical staff, space-rent to the hospital. A hospital blue-suit can manipulate each of those input numbers to come with whatever number he wishes.

The marginal cost of doing '1 more MRI' is very little, pretty much staff time and electricity. If you allocate fixed expenses, you can make 'cost' to be whatever you want it to be.
 
weilke said:
'Cost' in a MRI is difficult to calculate. What do you factor in ? Capital expense for the magnet, maintenance contract, helium bill, staff expenses for technical staff, space-rent to the hospital. A hospital blue-suit can manipulate each of those input numbers to come with whatever number he wishes.

The marginal cost of doing '1 more MRI' is very little, pretty much staff time and electricity. If you allocate fixed expenses, you can make 'cost' to be whatever you want it to be.
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This was what the hospital was charging the investigator who submitted the proposal. I am not privy to the mechanics of how the number was determined.
 
steingar said:
This was what the hospital was charging the investigator who submitted the proposal. I am not privy to the mechanics of how the number was determined.
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Oh, it involves a body orifice.

When the task is to extract 'other peoples money' out of a foundation, the number will be bigger than when it comes to justifying the size of the service during budget negotiations.

The point being: The fixed annual cost of operating an MRI facility is large. Once you have made that 'nut', the marginal cost of each individual study is very little. Neither of these numbers has anything to do with what is charged to insurance and even less with how much is charged to a self-paying individual.
 
weilke said:
When the task is to extract 'other peoples money' out of a foundation, the number will be bigger than when it comes to justifying the size of the service during budget negotiations.

The point being: The fixed annual cost of operating an MRI facility is large. Once you have made that 'nut', the marginal cost of each individual study is very little. Neither of these numbers has anything to do with what is charged to insurance and even less with how much is charged to a self-paying individual.
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I did not intimate that the amount was similar to what would be charged to anyone in any situation. I simply stated my own experience with what a hospital charged a researcher. I assume they didn't charge the researcher so little that they would loose money on the deal.
 
In some ways pricing of a medical test or procedure is like the pricing of an airline ticket. One big difference is that physicians and hospitals may have contracts with Medicare and insurance companies that place restrictions on what they can charge including rules that affect minimum pricing.
 
If you wind up paying out-of-pocket, you may find it advantageous to go someplace like where I live (Queens, NY), where freestanding MRIs outnumber hot dog stands. The competition is pretty intense, and I suspect you could negotiate a good cash price.

FWIW, the last time I had an MRI, there was some doubt whether the insurance company would pay for it. They eventually did, but in the meantime, I found out that the self-pay price if paid by cash or good check would have been $475.00, plus something like $75.00 for the radiologist to read it, and $5.00 if I wanted a copy on CD-ROM.

This was for an abdominal MRI about five years ago. The price sheet said something like $1,500.00, incidentally. But those prices apparently are meaningless. The self-pay COD rates were actually much lower.

-Rich

EDIT: I have a guest room.
 
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RJM62 said:
If you wind up paying out-of-pocket, you may find it advantageous to go someplace like where I live (Queens, NY), where freestanding MRIs outnumber hot dog stands. The competition is pretty intense, and I suspect you could negotiate a good cash price.

FWIW, the last time I had an MRI, there was some doubt whether the insurance company would pay for it. They eventually did, but in the meantime, I found out that the self-pay price if paid by cash or good check would have been $475.00, plus something like $75.00 for the radiologist to read it, and $5.00 if I wanted a copy on CD-ROM.

This was for an abdominal MRI about five years ago. The price sheet said something like $1,500.00, incidentally. But those prices apparently are meaningless. The self-pay COD rates were actually much lower.

-Rich

EDIT: I have a guest room.
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:thumbsup:

Medical billing is a somewhat bizarre environment.

There is allways a
- 'list price'
- medicare rate
- 20 different commercial payor rates
- whatever you can haggle out as a cash paying customer

The 'list price' is allways the highest and nobody should EVER feel obligated to pay it. Whether a cash price is better than the rate you would get through your health insurance depends on the local competitive situation, your negotiation skill and the question whether the imaging center accepts medicare assignment (if they do, they officially can't charge you less than they charge medicare, they still may work with you but there may have to be some wink-wink steps involved in the process).
 
Update from the OP. Hopefully this thread will be of some use to someone else faced with the same situation down the road:

- I conferred via email with Dr. Bruce. He more than lives up to his reputation as a great guy. His advice was invaluable.

- I ended up having to pay cash for my MRI. As suggested, I called around to various imaging places and eventually got it done for $550.

- My oncologist was kind of grumpy about having to write the letter for the FAA and order the MRI. She kept insisting that the MRI was not necessary. She asked me for the FAA's phone number so she could call them and tell them they were wrong. (Umm, I don't think that's going to be helpful . . .) But eventually she came around.

- I had my appointment with the AME yesterday. I delivered to him: doctor's notes, surgical note, pathology reports (original melanoma and surgical), MRI report and oncological status report (which is just a letter from my oncologist). The AME said everything appeared to be in order and that he would ship it off to the FAA.

- Now I've just got to wait. The AME said one month to two months.

Thanks again to everyone for their advice and support, especially Dr. Bruce.
 
Unregistered said:
Update from the OP. Hopefully this thread will be of some use to someone else faced with the same situation down the road:

- I conferred via email with Dr. Bruce. He more than lives up to his reputation as a great guy. His advice was invaluable.

- I ended up having to pay cash for my MRI. As suggested, I called around to various imaging places and eventually got it done for $550.

- My oncologist was kind of grumpy about having to write the letter for the FAA and order the MRI. She kept insisting that the MRI was not necessary. She asked me for the FAA's phone number so she could call them and tell them they were wrong. (Umm, I don't think that's going to be helpful . . .) But eventually she came around.

- I had my appointment with the AME yesterday. I delivered to him: doctor's notes, surgical note, pathology reports (original melanoma and surgical), MRI report and oncological status report (which is just a letter from my oncologist). The AME said everything appeared to be in order and that he would ship it off to the FAA.

- Now I've just got to wait. The AME said one month to two months.

Thanks again to everyone for their advice and support, especially Dr. Bruce.
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From the school of hard knocks: Take a copy of that letter, and of that MRI and the path report, surg note, doc's note and SHIP THEM OFF TO FAA yourself, certified. When you get the delivery confirm, start calling 405-954-4821 on the NONCONSEQUITIVE days. This is called "own your own medical". You have no idea if the shipment from the AME office ever got out, or if OKC ever got it, if you rely on the medical office. You might wait two months with NOTHING HAPPENING. PREVENT that.

When you have made the third call, ask the AME to call OKC. You can get certified on that very day.
 
Well, after many calls by me and the AME, my medical certificate finally arrived in the mail yesterday.

I had to read the paperwork a few times to understand it.

A couple of things of interest:

- The authorization is for six years (through 5/2017) rather than the five I expected. This means another MRI to pay for.

- The enclosed medical certificate was only good for one year.

- I am required to return to the AME every 12 months with a new MRI and status report, but I only have get a physical exam every two years.

Going to be a hassle, but at least I can fly again.
 
:thumbsup:

Once you are back to flying, the hassle will be forgotten. Congrats.
 
If you are still negative after five years out, petition them for a letter of eligibility. They will cut you loose. There is no such thing as a five-year AME ASSISTED SI (It's a bureaucracy, remember?). They are all for "six" (usually the airman loses the four months it took to get the SI), unless he's used somebod to expeditie the process (ten days).

You did good, and just pray that the thing didn't get out and shows its head afer 4 1/2 years......now go enjoy.
 
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