PET scan not covered by insurance?

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kgasmart
kgasmart Member Posts: 61 Member

Just got an EOB (explanation of benefits) yesterday for the PET scan I had in early August, the insurance company has decided it was "medically unnecessary" and isn't going to pay for it.

 

Any of you folks run into this? In retrospect I or my rad onc should have sought preauthorization, but I admit it didn't even occur to me - aren't PET scans after treatment ends routine to determine if there's any cancer remaining? If insurance doesn't pay for the PET scans, what are you supposed to do, sit around and wait 'til you've got a visible new tumor?

 

Grrr....

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  • wbcgaruss
    wbcgaruss Member Posts: 2,316 Member
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    Appeal Process

    I would think if they paid for a PET scan before they would pay for the follow-up. It seems pretty standard on here from reading over the years that a follow-up PET after treatment is the norm. I would check with your insurance for the way to appeal it and possibly get your doc involved as he can call them, email what they need or give you documentation to send with your appeal to back you up.

  • bugsyboy
    bugsyboy Member Posts: 39
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    Appeal

    My Primary Care and I thought it would be a good idea for me to get a PET Scan.  This was December 2015.  My last radiation was October 2014.  She ordered it and the Hospital called to schedule in December 2015.  I received an EOB in April 2016 denying the procedure.  I wrote a letter to BCBS and stated that the test was ordered by my PC, who ordered it because she thought it was necessary by exercising prudent clinical judgement while considering all factors, including metastasis of HPV Squamous Cell Cancer, family history, and my health at the time.  I also included a letter from my PC stating the same.  I informed BCBS that when the Hospital called to schedule, given the cost of the procedurre, I thought their calling and battery of questions/instructions was part of the preauthorization process; especially given the cost of the procedure.  I was able to include the date and time of the phone call and the Hospital person's name with whom I spoke.  I won my appeal.  I hope you win yours.

    Best of luck.

    Bugsy

  • kgasmart
    kgasmart Member Posts: 61 Member
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    bugsyboy said:

    Appeal

    My Primary Care and I thought it would be a good idea for me to get a PET Scan.  This was December 2015.  My last radiation was October 2014.  She ordered it and the Hospital called to schedule in December 2015.  I received an EOB in April 2016 denying the procedure.  I wrote a letter to BCBS and stated that the test was ordered by my PC, who ordered it because she thought it was necessary by exercising prudent clinical judgement while considering all factors, including metastasis of HPV Squamous Cell Cancer, family history, and my health at the time.  I also included a letter from my PC stating the same.  I informed BCBS that when the Hospital called to schedule, given the cost of the procedurre, I thought their calling and battery of questions/instructions was part of the preauthorization process; especially given the cost of the procedure.  I was able to include the date and time of the phone call and the Hospital person's name with whom I spoke.  I won my appeal.  I hope you win yours.

    Best of luck.

    Bugsy

    Thanks for the detailed reply!

    I'm seeing my rad onc for a follow-up this week, he's the one who ordered it; like you, given the cost of the procedure, I would have expected his office to have called and preauthorized it. If not, did he simply assume it would have been OK, given his experience with other patients and the fact he considers a PET scan a routine and medically necessary follow-up to check for evidence of disease? I'm certain he'll be happy to write a letter to that effect.