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Small Cell lung cancer - denied Pet / CT SCAN

dsv216
Posts: 1
Joined: Sep 2009

Hi
my mom who is 65 was diagnosed with small cell lung cancer. she has had radiation and chemo and so far so good.
I want to know if anyone has encountered being denied a PET /ct scan from insurance company she has keystone
we live in Philadelphia.
we are being treated at Jefferson Kimmel Center, which I am told is one of the best.
my moms doctors order the Pet scan only for the insurance company to deny it , they say that small cell lung cancer is denied.
has anyone had this problem. I fight with them,and had on paid for the second we paid out of pocket but I appealed the decision and they did overturn it, but I havn't recv'd any refund. now she needs it again, to further plan out her treatment.
as the chest scan showed something in her lymph node. the doctor isn't convinced with this result and wants a pet scan.
which they have again denied. I don't understand, you pay to only be denied...
if anyone knows how I can get it or a phone number to call please help.
thank you and best wishes to all.

MichelleP's picture
MichelleP
Posts: 254
Joined: May 2009

Sometimes doctors use an "incorrect code" when requested certain tests and are therefore denied. First I would check with them and make sure. Then I would certainly file and appeal. Also, is your Mom a senior? If so, these insurance companies are required by law to cover anything that would be covered by medicare. We ran into that issue ourselves and they were forced to reverse their decision. Just call 1-800-MEDICARE if you want clarification for coverage. They are very helpful. Good luck and let us know what happens.

upnorthtex
Posts: 4
Joined: Aug 2009

My wife was told the same thing three years ago but the radioligist told us of a study that was going on at the time that paid for the PET as Medicare and our insurance would not. She's had several more scans since and they have paid for all of them. Oddly, the study is to see if PET scans help in the treatment and success rates. Don't know if the study is still going on but you should check with the radiology center. Good Luck,Art

clsmith
Posts: 83
Joined: Nov 2008

So Medicare doesnt pay for pet? Just went on Medicare on July, so this is interesting to me. I have nsclc. When i need a Pet again i will follow up on this,

Thank you for this info.

Cindy

hansie
Posts: 37
Joined: Jul 2008

ok... pet scans use radioactive sugars to show where cancer activity is present.The cancer lights up more than regular tissue because it is using more sugar than regular tissue.Cat scans are as described above...3d xrays.Pets are expencive,and usually only done once every 3 months.Cat scans are cheeper and in the case if small cell,adequate to find new growth as its usually pretty agressive and obvious.If your ins co is refusing pets less than 3 months apart thats sop...a cat could show new growth just as well,but if its ben 3 months or more id be fighting that insurance co. tooth and nail...good luck,i hope this helps.

lmisnkc2
Posts: 2
Joined: Jul 2009

Hi,
I had lung cancer back in May of this year and my insurance paid for 2 PET scans so far. I have Humana insurance. If I were you, you might call your congressman or state rep and have them look into this or perhaps their office can get you to someone who can hepl you. Best of luck to your mon and you. Linda

barbara1168
Posts: 2
Joined: Sep 2009

As another replyer has already said, they sometime miscode which then turns into a denial. Always file an appeal in writing before ever excepting a NO. Many times we received denials and everytime it was due to a bad code used.

Good luck and let us know how you make out.

ALCAMM4406
Posts: 1
Joined: Sep 2009

I am having the same problem. It must be Philadelphia. I am from Philadelphia, and my Mom is on my Dad's union policy (personal Choice) my dad just recently got on Medicare but my mom is not of that age yet she is only 61. She was diagnosed 5 years ago with SCLC and has never had a problem with getting a Pet Scan done. She had been cancer free until recently. She has been going through chemo and the oncologist has requested a pet scan to make sure the course of treatment is being effective. The day before her test the office called and said the insurance would not give authorization. She finally got to speak with someone at Personal choice and they told her Pet scans are only covered for non-small cell cancer not SCLC. They said they follow Medicare guidelines. Which makes absolutely no sense to me. I work for a DME company in Philadelphia, and I will see if I can get any info from them regarding this matter. If you find out anything please post it and I will do the same

Thank you

Alana

LisaBH
Posts: 1
Joined: Jul 2015

my brother has just gone through 6 rounds of the strongest two Chemo treatment's there is for lung, liver and Bone cancer and this is his second denial. I just found out that I have Agressive Breast cancer three weeks ago and I as well was denied A PET SCAN thats two different insurance companies . What's up with that ? I know they both didn't Send in the wrong numbers plus my insurance is now telling me I can't get prescriptions that have been ordered for me.

dennycee
Posts: 836
Joined: Mar 2011

The PET scan is not used in staging breast cancer.   It's a completely different process.  Having survived stage 4 lung cancethane now breast cancer I learned that things I anticipated for staging are not done.  With breast cancer there will be oncotyping.  Has your dr received the results of your oncotyping yet?  

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