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Post-treatment analysis of tumor status?

Will_Coons's picture
Will_Coons
Posts: 7
Joined: Feb 2014

Hi All -

I am one month post treatment and my chemo oncologist scheduled a PET scan to determine the staus of my tumor. My insurance company has refused to pay for it, stating that evidence suggests a PET scan is not conclusive for ascertaining the status of the tumor.

So what are my other options? Paying the $2500 out of pocket for the PET is not feasable, as I am still out of work.

Thank you for any advice.

Marynb
Posts: 1134
Joined: Aug 2012

What Insurance company? I would think that you could appeal this, as it is generally accepted standard of care. Has the cancer hospital been of help to you? When my pet scan was denied by BCBS, the hospital dealt with it for me. All reputable cancer centers deal with this stuff on a daily basis.

What does the insurance company recommend? There is a site that lists generally accepted protocols for cancer care. You should check the National Cancer Care Network (NCCN) site. That site lists the evidence based standards of care for specific cancers. You may have to login and create an account.
Good luck!

Will_Coons's picture
Will_Coons
Posts: 7
Joined: Feb 2014

I did not know of the NCCN - thank you for bringing it to my attention.

mp327's picture
mp327
Posts: 3020
Joined: Jan 2010

I have posted this before, but will again. 

 

The NCCN guidelines that Marynb referred to say that for complete remission cases, follow-up protocol is as follows:

DRE every 3-6 months for 5 years

Anoscopy every 3-6 months for 5 years

Inguinal node palpation every 3-6 months for 5 years

 

For tumors of T3-T4 status at time of diagnosis, follow-up protocol includes CONSIDERATION of chest/abdominal/pelvic imaging annually for 3 years

 

So you can see from the above information that follow-up PET scans are not recommended and CT scans are only suggested in cases of T-3, T-4 tumors.  This is most likely the reason that your doctor's request for a PET scan has been denied by your insurance company.  For the first 3 years after my treatment, my oncologist ordered regular PET scans for me and my insurance company kept approving them.  However, my insurance coverage switched to another company and they denied his later requests, so he has ordered CT scans for me instead, which they have paid.  I have probably been over-scanned--it's a long story, which I will not going in to.  However, if your doctor is set on getting the PET scan, he can try to get it approved by your insurance company by writing a letter explaining the medical necessity of getting the scan.  If still denied, then a CT scan or MRI can be ordered, but may also require pre-approval. 

You are not the first person who has had this experience with insurance denial of an ordered scan.  The insurance companies are in the business of NOT paying for services, especially those that they feel are unnecessary.  The NCCN guidelines are very good, as they lay out both the treatment and follow-up protocol.  Unfortunately, doctors are all over the place when it comes to follow-up.  If the insurance companies are using the guidelines as their measure as to whether or not to approve a scan, then that's what creates the disagreements.

I hope you and your doctor can get this all worked out to everyone's satisfaction.

Will_Coons's picture
Will_Coons
Posts: 7
Joined: Feb 2014

I love that this site gives me more information than my medical providers offer; it empowers me for when I go in for my next office visit. Thank you!

mp327's picture
mp327
Posts: 3020
Joined: Jan 2010

You are most welcome!

If you wish to view the NCCN guidelines in their entirity, I have posted the address for their website below.  After a short registration, you will have access to lots of good information about anal cancer and the most current treatment and follow-up protocols.

http://www.NCCN.org

 

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