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Problems with insurance authorizing a PET scan for breast cancer

patty240
Posts: 5
Joined: Nov 2012

I've never had a PET scan, have had surgery for removal of breast cancer, high grade, stage 3,with lymph node involvement. Anthem Blue Cross has denied me a PET 3 times and has denied a bone scan. Any other breast cancer patients having problems getting the PET? I don't know why they continually deny my PET. Any advise on what to do?

mollyz's picture
mollyz
Posts: 739
Joined: Sep 2010

I had problems @ first, it might be the wording of the order sent to them,mine had to be sent 2 or 3 times,they need all your information beginning with the first diagnoses if your Dr. is sending you need a pet/scan and for no reason then it will deny it,it really has to be detailed. sorry this is happening to you,I had my first pet/scan before any surgery or anything,did you have a lumpectomy or mastectomy? ~~MollYZ~~

missrenee's picture
missrenee
Posts: 2137
Joined: Apr 2010

With all you've gone through and now they make you even more frustrated. I have had so many CTs, MRIs, PETS I can't even count them. I know all insurance/coverage is different, but keep being the squeaky wheel. Don't give up.

Hugs, Renee

Pink Rose
Posts: 495
Joined: Nov 2012

Call your insurance company and question them as to why they aren't allowing the PET scan. Also, get the procedure code from your doctor. Maybe it is not the right code? Keep trying to get the PET covered.

Good luck!

patty240
Posts: 5
Joined: Nov 2012

in Aug. I was diagnosed with breast cancer. I never had a PET scan prior to surgery. I had a mastectomy and then the DR. said I needed chemo. Three Oncologists said I needed a PET scan. The 4th doctor would not even give me an initial consult without a PET scan for her to review. I have Anthem Blue Cross. The CT scan said I have a cyst in my lumber spine. I hope it doesn't turn into cancer. Anthem also denied a bone scan. Am I the only stage 3 high grade cancer patient with lymph node involvement that the insurance company keeps denying? They keep saying that the PET scsn is not medically necessary

VickiSam's picture
VickiSam
Posts: 8499
Joined: Aug 2009

customer service -- I know there is an 800#. Explain the situation, and ask to
special with a Supervisor - Department head.

Please note -- keep record of whom you have spoken with, dates -- telephone extension,
and employee ID. You may get transferred around to several individuals -- however,
if you carry the policy (or husband), you will get this issue resolved, with a little pushing,and kindness.

If there is a code that you Oncologist/Doctor must use in order to get PET scan
approved -- please make sure to jot that down.

I had Anthem Blue Cross here in So. California during my BC illness, journey, and
chemo --- never had an issue after I made my first phone call regarding coverage,
in network providers, hospitals, etc.

Let us know .. what the outcome is.

Strength, Courage and HOPE for a Cure.

Vicki Sam

patty240
Posts: 5
Joined: Nov 2012

I have called the Anthems 800 number numerous times. The radiologists has called them and advised them of the lesion on my spine. Anthem still says the PET is not medically necessary. I will be getting rid of Anthem next year when open enrollment comes around. I have nothing good to say about Anthem Blue Cross, and I also live in southern California. I pay good money for that insurance and they have the odasidy to treat me this way. I plan on filing a complaint on them with the state insurance commission.

SIROD's picture
SIROD
Posts: 2204
Joined: Jun 2010

I also have Anthem BC/BS and they have never denied a PET scan for me. My very first one was only a little over 4 years ago and was recommended by the radiologist for clinical correlation when my 3rd recurrence showed widespread pulmonary, pleural metastasis and pleural effusion. They did find cancer in the celiac nodes, which was nice to know. The PET scan I had last year was over $5,000.00 while an MRI was 1200.00. Unless there is a good reason for it, they will deny it.

MRI might be better for the lumber spine and isn't as costly. I haven't had a lot of PET scans and it does surprise me to read how often the other ladies have had them. I don't do scans unless I believe they really are needed.

Bone scans are a waste of time. If there is an uptake, it doesn't state what it is, it could be arthritis, cancer, an injury. Why bother with something that is so unspecific.

I don't think a cyst turns into cancer. Tumors are solid and cyst are fluid.

Why do you have four oncologist? If the one who will be your oncologist wrote/ or called Anthem and stated the reason that this is needed, they most likely will approve. Pick one oncologist and then see where it goes.

Wishing you the best of luck as you begin your bc journey.

Doris

New Flower
Posts: 4134
Joined: Aug 2009

Please use a formal appeal process for any denied services. If you are a stage 3 with more than 3 lymph positive nodes, they must approve you for both PET and bone scan. Please be your own advocate and request denial in writing. Then you need to appeal it going through a formal process. Your EOB usually has info on a formal appeal process. It used to be on the back of paper. Look at website for your insurgence and you will find information about it.
Hugs and let us know about your progress

New Flower
Posts: 4134
Joined: Aug 2009

I also live in SoCal. Please ask them for a written denial

survivorbc09
Posts: 4378
Joined: Jun 2009

I'm sorry Patty that your tests have been denied. I've never had that happen. I think partly because my onco always makes the request and from what he has told me, he makes it sound like the test or tests are absolutely needed as there is a question or an area of concern. He doesn't actually lie, but, I think, from what he says, he words it in a way to make sure my tests are approved.

Keep trying!

Jan

AMomNETN
Posts: 242
Joined: Apr 2010

I wish you luck. My insurance denied my PET scan as not medically necessary. I'm sure that is what yours is doing too. I spoke to mine and unless there is an indication that my cance has returned or whatever. They will not approve a PET scan. I have BCBS TN. They have approved a CT Scan the past 2 years and I'm due another one soon. It is the way they work because PET Scans are extremely expensive. I just accepted it and have gone on. Ask your onc about doing a circulating tumor test. They check your blood to see if any cancer cells are lurking aroung. I hope this helps.

Janie

AngieD's picture
AngieD
Posts: 504
Joined: Sep 2011

I haven't had or needed a PET scan, but I had a bone scan when I was first diagnosed and being staged. Can your cancer center social workers get involved? Mine did that for getting me approved for coverage for the BRCA tests since my family history did not meet the guidelines.

Good luck!

Angie

Angie2U's picture
Angie2U
Posts: 2993
Joined: Sep 2009

I've never had a Pet scan either, but, I have had MRI's, CAT scan's and a bone scan. I had no problem with my insurance company in getting these tests approved. You need to call them and see what the problem is and why you were denied.

Good luck!

Alexis F's picture
Alexis F
Posts: 3604
Joined: May 2009

Did your oncologist order the PET scan with your insurance? If he did, can you call him and see if there is another code or something that he could use so that your insurance will pay for it? I know the procedure or diagnostic code is what determines whether you can get coverage or not.

Good luck, Lex

kcred69
Posts: 5
Joined: Nov 2012

Contact your insurance company personally, ask why they are denying the PET scan, and than submit a complaint to the department that handles problems. File a complaint with your states managed insurance commissioner or board as well. Ask for a copy of the request for PET from your doctor assure that they incorporating the right diagnosis and reason for the need for authorization. Usually if you have had a PET within a year they will deny. So if this is the case fight like heck. Don't take no for an answer, and don't wait for them to call you back keep on them until you get an answer.

jnl's picture
jnl
Posts: 3873
Joined: May 2009

Did you appeal their decision Patty? Were you able to get the PET scan?

I hope so!

Hugs Leeza

kcred69
Posts: 5
Joined: Nov 2012

Contact your insurance company personally, ask why they are denying the PET scan, and than submit a complaint to the department that handles problems. File a complaint with your states managed insurance commissioner or board as well. Ask for a copy of the request for PET from your doctor assure that they incorporating the right diagnosis and reason for the need for authorization. Usually if you have had a PET within a year they will deny. So if this is the case fight like heck. Don't take no for an answer, and don't wait for them to call you back keep on them until you get an answer.

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