Anyone battled with Medicare to pay for CA 125 testing ?

nancygt
nancygt Member Posts: 86
in Uterine/Endometrial Cancer #1
Since it has been a reliable early warning indicator, my doc has tested me regularly the last few years. I went on medicare 6-1 and have now noticed medicare is declining to pay for CA 125 tests. Since lab was not billing me, I just noticed as I started to gather year end receipts,etc.My old insurer only paid thenm $11 of the $175 gross thy billed for each test so maybe lab is writing it off-they will not confirm. Medicare would only tell me that it was declined for "medical necessity"-they would not even tell me what the diagnosis code was on the claim-I hate bureacracy.I called lab and they said they showed 179 Uterine Cancer. I called my doc and his insurance person is surprised. I suppose I can file an appeal and see what they but I thought someone here might have experience. Any input/suggestions will be appreciated.

Comments

  • Kaleena
    Kaleena Member Posts: 2,088 Member
    #2
    Hi Nancy:
    I really dislike
    Hi Nancy:

    I really dislike that "medically necessary" bit. I had changed insurance companies recently. Prior to that I was able to get scans, PET Scans, etc. New insurance now says that it was not medically necessary! I called and complained several times. I am now in appeals. I had to go instead for a CT scan instead of a PET becasue I was way overdue for a scan. The insurance companies don't even look at a chart or work with the doctor. They just go by a "rule book". UGGG!!!

    I would shoot for the appeal. My best to you!

    Kathy
  • lkchapman
    lkchapman Member Posts: 106
    #3
    182.0
    Hi Nancy,
    If you had endometrial cancer which most uterine adenocarcinomas and upsc are, it would could to 182.0 not 179. 179 is a nonspecific uterine cancer code. You need to make sure they are coding the correct code. Medicare should pay for the ca125 for 182.0.

    Good luck.
    Laura
  • daisy366
    daisy366 Member Posts: 1,458 Member
    #4
    lkchapman said:

    182.0
    Hi Nancy,
    If you had endometrial cancer which most uterine adenocarcinomas and upsc are, it would could to 182.0 not 179. 179 is a nonspecific uterine cancer code. You need to make sure they are coding the correct code. Medicare should pay for the ca125 for 182.0.

    Good luck.
    Laura

    Good info
    Nancy, I hate the bureaucracy too and I'm headed to medicare soon. It scares me to think I will have to battle again. I duked it out with Aetna and now will hopefully get my first PET with BC/BS in Jan without a fight.

    Laura. I just looked at a lab order and I'm coded 183 (endometrial and UPSC) not 182. Hmmm?

    Mary Ann
  • nancygt
    nancygt Member Posts: 86
    #5
    daisy366 said:

    Good info
    Nancy, I hate the bureaucracy too and I'm headed to medicare soon. It scares me to think I will have to battle again. I duked it out with Aetna and now will hopefully get my first PET with BC/BS in Jan without a fight.

    Laura. I just looked at a lab order and I'm coded 183 (endometrial and UPSC) not 182. Hmmm?

    Mary Ann

    checking out 182 and 183
    Thanks for that info-I wonder if the 179 has just gotten carried forward and did not get noticed until Medicare.So far medicare has not been a problem but as I get into 3rd and 4th line chemo, I think it will really be important to have correct coding reflecting UPSC, especially if we want to try Avastin.
  • carolenk
    carolenk Member Posts: 907 Member
    #6
    nancygt said:

    checking out 182 and 183
    Thanks for that info-I wonder if the 179 has just gotten carried forward and did not get noticed until Medicare.So far medicare has not been a problem but as I get into 3rd and 4th line chemo, I think it will really be important to have correct coding reflecting UPSC, especially if we want to try Avastin.

    ICD-9 billing code
    The billing code 183.0 is used for "malignant neoplasm of the ovary & other uterine adenexa."
  • lkchapman
    lkchapman Member Posts: 106
    #7
    daisy366 said:

    Good info
    Nancy, I hate the bureaucracy too and I'm headed to medicare soon. It scares me to think I will have to battle again. I duked it out with Aetna and now will hopefully get my first PET with BC/BS in Jan without a fight.

    Laura. I just looked at a lab order and I'm coded 183 (endometrial and UPSC) not 182. Hmmm?

    Mary Ann

    UPSC
    Hi Mary Ann,
    UPSC will still code to 182.0. 182.0 doesn't indicate morphology only the site of the cancer. Morphology codes are used to describe cell type such as adenocarcinoma vs papillary serous carcinoma. They begin with an M. Off hand I can't remember what the morphology code is for papillary serous carcinoma.
    Maybe your doctor was using 183.0 (ovary) to get some test paid for?(Pet scan for instance)

    Laura
  • daisy366
    daisy366 Member Posts: 1,458 Member
    #8
    lkchapman said:

    UPSC
    Hi Mary Ann,
    UPSC will still code to 182.0. 182.0 doesn't indicate morphology only the site of the cancer. Morphology codes are used to describe cell type such as adenocarcinoma vs papillary serous carcinoma. They begin with an M. Off hand I can't remember what the morphology code is for papillary serous carcinoma.
    Maybe your doctor was using 183.0 (ovary) to get some test paid for?(Pet scan for instance)

    Laura

    Thanks Laura.

    Thanks Laura.

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