Medicare coverage for second pathologist's opinion

Tech70 Member Posts: 70 Member

I just checked my Medicare online account and the billing for a second opinion of my confirmatory biopsy slides by Johns Hopkins was denied by Medicare.  Is this normal/usual?  If their analysis overrules the first pathologist's report, $250 is money well spent.  In either case, I can afford it and value the second opinion.

As background, my initial biopsy found one core positive, 10% of core Gleason 3+3.  Confirmatory biopsy found two cores positive, 3% and 7% of the cores, Gleason 3+4.  Because a different lab was used for the second analysis and because of favorable Oncotype DX score on the first biopsy samples, I decided to have a second review by JH and Oncotype testing of of the second biopsy samples before deciding to forego AS that was previously planned.


  • Max Former Hodgkins Stage 3
    Max Former Hodgkins Stage 3 Member Posts: 3,788 Member

    Arguing is what insurance adjusters do. They are among the lowest forms of humanity.

    Policies, coverage, medical facilities, they all differ.   Me, paying the $250 and avoiding speaking to insurance claims personnel would be a bargan.

    The vast majority of PCa pathology reports, however, are usually pretty accurate. Guys write about errors here, but the guys here are not typical of US PCa patients, of which not one in 1,000 has ever even heard of this Board.   

    Compared to many other cancers, analyzing PCa cells is simple.  My other cancer for instance, Lymphoma, has over 65 recognized variants at WHO (the World Health Organization).  Many of these strains are never seen in a career by professional hematologists, and treatment among each variant can vary wildly, such that a set of drugs used against one is worthless against another.

    When a PCa biopsy is wrong, it is almost always wrong in under-estimating Gleason. Ergo, you can reasonably assume you have either what your first pathology report stated, or something a bit WORSE, and respond accordingly.


  • hopeful and optimistic
    hopeful and optimistic Member Posts: 2,333 Member


    I think that if one's doc orders the second opinion it is more likely to be covered by medicare, than if you give instructions to the office to send  for the second opinion.

    "the gleason score is one of the most important pathologic determinants"

    "do not be afriad to ask for this additional assurance that you Gleason sccoreis accurate, because this is a MAJOR factor in your decision making process"

    "if your Gleason sore has been given an interpretation that is lower or higher than that rendered by an expert, you may undertreat or overtreat your cancer based onerroneous information"

    Source: A Primer on Prostate Cancer..Stephen B. Strum, MD, FACP medical oncologist specializing in prostate cancer


  • Tech70
    Tech70 Member Posts: 70 Member
    edited May 2021 #4
    Had two sample re-evaluated by J-H.

    In neither case did Medicare pay.

  • Tech70
    Tech70 Member Posts: 70 Member
    edited May 2021 #5
    Tech70 said:

    Had two sample re-evaluated by J-H.

    In neither case did Medicare pay.

    Heaven help me, I just replied to my own post.

    Foot in Mouth

  • ryancfmurray
    ryancfmurray Member Posts: 1
    edited May 2021 #6
    I totally agree.

    Why don't you try to find another clinic that treats its patients more responsible? You said that you are rich enough to find the best doctor in your city, I am sure that you will be able to contact a good specialist who will find a way to help you. There are many different healthcare factoring companies that can help you get in touch with a good specialist, you only need to want it. Look at the Internet, to find someone who will be able to solve your problem and assign an effective solution.