Denied scans---your experiences

ratface
ratface Member Posts: 1,337 Member
in Head and Neck Cancer #1
My insurance company denied my upcoming scans. Their decision is based on the NCCN guidelines, Follow-up recommendations. These may be the same criteria used by your insurance carrier. For comparison, I was base of the tongue, stage 4 and have had small lung spots show up on previous scans without significant change. This would have been my 8th scan. I'm roughly three years post treatment. They hinge their argument on a statement within the guidelines, specifically the word, "asymptomatic", which reads as follows:

"Further re-imaging as indicated based on signs/symptoms; not routinely recommended for asymptomatic patients"



My insurer is BCBS of Illinois. I'm looking to compare what is typical in the industry among insurers. Are you folks being approved or denied past the three year period and what are your particular circumstances regarding signs/symptoms? Do I have an argument for an appeal?

Comments

  • jtl
    jtl Member Posts: 456
    #2
    Kind of a catch 22. Alot of
    Kind of a catch 22. Alot of us never had symptoms so I guess until something becomes obvious and perhaps too late they don't want to pay for test to catch it early. Unfortunately this is getting to be the norm with insurance companies.
  • Skiffin16
    Skiffin16 Member Posts: 8,305 Member
    #3
    August....
    I'll let you know in August, that's when I'm due for another PET, and that will be out past the three year post treatment period.

    So far I've had no problems being approved.

    JG
  • KTeacher
    KTeacher Member Posts: 1,103 Member
    #4
    Yes!!!
    Not 3 years not even a year after recurrance. Is the BC part of the BS Blue Cross? My blood pressure is beginning to raise. I was told a different story from everyone I contacted, Blue Cross rep said they don't make the decision it goes to another group that will not talk to the patient. I was spinning. Seems like it ended up that Blue Cross and Stanford are not playing well, my local rad doc ordered it locally and it was approved in 2 days. PM me, I will get some more info. to you. I finally got a clean scan.
  • Kent Cass
    Kent Cass Member Posts: 1,898 Member
    #5
    KTeacher said:

    Yes!!!
    Not 3 years not even a year after recurrance. Is the BC part of the BS Blue Cross? My blood pressure is beginning to raise. I was told a different story from everyone I contacted, Blue Cross rep said they don't make the decision it goes to another group that will not talk to the patient. I was spinning. Seems like it ended up that Blue Cross and Stanford are not playing well, my local rad doc ordered it locally and it was approved in 2 days. PM me, I will get some more info. to you. I finally got a clean scan.

    3 years-
    Just had my 3-year PS/CT in early-April, and BCBS of Iowa had no problem with it. Did kinda freak me out, though, that they didn't get it approved until within an hour of the actual scan, and the radiology center didn't get word of the approval until after I got there. I mean, this thing had been planned long ago. Could be my ENT office hadn't crossed a "t" or dotted an "i." We have now switched to United Healthcare, as of 5/1/12, and I got no clue on how they're gonna do with a 4-year scan. FYI, ratface.

    kcass
  • Pam M
    Pam M Member Posts: 2,196
    #6
    No PETS for Me
    I only got PETS to diagnose, and to check post-treatment. Then the rule was - no PET without a prior dirty CT. So my seven month out PET was denied - til the CT came back bad. Then I got one PET after my last surgery - as long as I have clear CT scans, I get no PETs (per insurance, not docs).
  • Jan Trinks
    Jan Trinks Member Posts: 477
    #7
    Same things; different reason
    Ratface:

    Back in 2007 Charlie was diagnosed with Acid Reflux and placed on Nexium. At the time we had BCBS (Blue Choice) ins. After his Nexium samples ran out we took rx to be filled. BCBS wasn't going to pay for because they wanted him to take some over the counter stuff which didn't work and some other less expensive rx which didn't work either; the Nexium did. I was livid and called BCBS and between me and the gastro's nurse we won out. It just infuriates me that some bunch of supposedly "know it alls" sit around and decide whether you receive treatment or meds your docs prescribe and I told them so. Went so far as to tell them what makes them think they know what he needs and doesn't need; they're not the ones that see him or treat him. I consider that victory to be high on my list of accomplishments! Good luck. I can't believe they deny scans regardless how far post treatment you may be. How they going to keep check on things w/o scans every so often? Good luck and will say a prayer for you!

    Jan (Basketcase)
  • D Lewis
    D Lewis Member Posts: 1,581 Member
    #8
    What KT Teacher said...
    The operative word you used is "asymptomatic." So, let them know about your real on-going symptoms. I got the same denial response from BCBS when my Stanford doctors tried to schedule my 2-year followup PET-CT. The two key symptoms you need to remind them of are your 'increasing hoarseness' and 'aspirating food.' We all know we have these at times. You need to remind your doctor that they happen and that you have concerns.

    Deb
  • ratface
    ratface Member Posts: 1,337 Member
    #9
    D Lewis said:

    What KT Teacher said...
    The operative word you used is "asymptomatic." So, let them know about your real on-going symptoms. I got the same denial response from BCBS when my Stanford doctors tried to schedule my 2-year followup PET-CT. The two key symptoms you need to remind them of are your 'increasing hoarseness' and 'aspirating food.' We all know we have these at times. You need to remind your doctor that they happen and that you have concerns.

    Deb

    arrived at a compromise
    Just to update the thread, I appealed and just heard that they will approve two of the four scans. Approved neck and chest, denied head and abs. Scheduled for August now. If you find yourself in a similar situation and have an appeal process, it's worth a try.
  • jtl
    jtl Member Posts: 456
    #10
    ratface said:

    arrived at a compromise
    Just to update the thread, I appealed and just heard that they will approve two of the four scans. Approved neck and chest, denied head and abs. Scheduled for August now. If you find yourself in a similar situation and have an appeal process, it's worth a try.

    Pet/CT eyes to thighs is the
    Pet/CT eyes to thighs is the protocol. Either one combined scan or seperate CT and Pet so what are the 4 scans?
  • ratface
    ratface Member Posts: 1,337 Member
    #11
    jtl said:

    Pet/CT eyes to thighs is the
    Pet/CT eyes to thighs is the protocol. Either one combined scan or seperate CT and Pet so what are the 4 scans?

    4 scans
    head, neck, chest , and abs. I'm only getting the neck and chest. Leaving me naked on the top and bottom.
  • Greend
    Greend Member Posts: 678
    #12
    Help for this
    If your Doctor says you need a treatment yet a clerk at the insurance office says "no" then politely ask the person to allow you to speak with a medical doctor to find you why they disagree with your doctor's recommendation. It has never failed me. You will hear "Oh well let me check with him/her and get back with you." I have yet to be denied on legitimate requirements.
  • George_Baltimore
    George_Baltimore Member Posts: 303
    #13
    Greend said:

    Help for this
    If your Doctor says you need a treatment yet a clerk at the insurance office says "no" then politely ask the person to allow you to speak with a medical doctor to find you why they disagree with your doctor's recommendation. It has never failed me. You will hear "Oh well let me check with him/her and get back with you." I have yet to be denied on legitimate requirements.

    Insurance
    From my original diagnosis in Jan. 2004 til Dec. 2008 when SS Disability enabled me to become Medicare eligible, I had 11 MRI's and 4 PET scans. They were ALL paid for by BCBS except for my deductibles. Since Dec. 2008 til present, I've had 2 MRI's and 2 PET's that were covered COMPlETELY by Medicare and BCBS Medi-gap. This doesn't include many CT scans for other problems. They too were covered completely since 2008. Just in 2004, between treatments and tests, BCBS paid out over $156,000 on me. I don't understand why they are giving you a hard time unless it's the way your doctor's office is coding their services. I've gotten large bills in the past from doctors and hospitals that were corrected once they went back, changed their codes and resubmitted their bills. It might be something that you should look into.

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