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Anyone battled with Medicare to pay for CA 125 testing ?

nancygt
Posts: 86
Joined: Jan 2010

Since it has been a reliable early warning indicator, my doc has tested me regularly the last few years. I went on medicare 6-1 and have now noticed medicare is declining to pay for CA 125 tests. Since lab was not billing me, I just noticed as I started to gather year end receipts,etc.My old insurer only paid thenm $11 of the $175 gross thy billed for each test so maybe lab is writing it off-they will not confirm. Medicare would only tell me that it was declined for "medical necessity"-they would not even tell me what the diagnosis code was on the claim-I hate bureacracy.I called lab and they said they showed 179 Uterine Cancer. I called my doc and his insurance person is surprised. I suppose I can file an appeal and see what they but I thought someone here might have experience. Any input/suggestions will be appreciated.

Kaleena's picture
Kaleena
Posts: 1227
Joined: Nov 2009

Hi Nancy:

I really dislike that "medically necessary" bit. I had changed insurance companies recently. Prior to that I was able to get scans, PET Scans, etc. New insurance now says that it was not medically necessary! I called and complained several times. I am now in appeals. I had to go instead for a CT scan instead of a PET becasue I was way overdue for a scan. The insurance companies don't even look at a chart or work with the doctor. They just go by a "rule book". UGGG!!!

I would shoot for the appeal. My best to you!

Kathy

lkchapman's picture
lkchapman
Posts: 105
Joined: Jan 2011

Hi Nancy,
If you had endometrial cancer which most uterine adenocarcinomas and upsc are, it would could to 182.0 not 179. 179 is a nonspecific uterine cancer code. You need to make sure they are coding the correct code. Medicare should pay for the ca125 for 182.0.

Good luck.
Laura

daisy366's picture
daisy366
Posts: 1493
Joined: Mar 2009

Nancy, I hate the bureaucracy too and I'm headed to medicare soon. It scares me to think I will have to battle again. I duked it out with Aetna and now will hopefully get my first PET with BC/BS in Jan without a fight.

Laura. I just looked at a lab order and I'm coded 183 (endometrial and UPSC) not 182. Hmmm?

Mary Ann

nancygt
Posts: 86
Joined: Jan 2010

Thanks for that info-I wonder if the 179 has just gotten carried forward and did not get noticed until Medicare.So far medicare has not been a problem but as I get into 3rd and 4th line chemo, I think it will really be important to have correct coding reflecting UPSC, especially if we want to try Avastin.

carolenk's picture
carolenk
Posts: 909
Joined: Feb 2011

The billing code 183.0 is used for "malignant neoplasm of the ovary & other uterine adenexa."

lkchapman's picture
lkchapman
Posts: 105
Joined: Jan 2011

Hi Mary Ann,
UPSC will still code to 182.0. 182.0 doesn't indicate morphology only the site of the cancer. Morphology codes are used to describe cell type such as adenocarcinoma vs papillary serous carcinoma. They begin with an M. Off hand I can't remember what the morphology code is for papillary serous carcinoma.
Maybe your doctor was using 183.0 (ovary) to get some test paid for?(Pet scan for instance)

Laura

daisy366's picture
daisy366
Posts: 1493
Joined: Mar 2009

Thanks Laura.

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