Insurance Co denied 6 month PET / Any suggestions?

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  • mls351w
    mls351w Member Posts: 90
    #22
    jtl said:

    Hi Tim,
    I am on Medicare so
    Hi Tim,
    I am on Medicare so my situation is different but I had a PET/CT at 3 months post and another 7 months later these were in addition to my diagnostic scan to locate the primary cancer site. Originally I had a CT scan but that did not show anything unusual, the next day I had a PET and the primary was found. The following was taken from the Cleveland Clinic website:

    "In head and neck tumors, recurrences
    often are challenging to detect by CT or MRI
    alone, as surgery or radiation therapy can significantly
    distort the normal anatomic landmarks.
    Although PET by itself accurately
    detects tumor recurrence, PET/CT more precisely
    delineates the enhanced FDG uptake,
    making it easier to differentiate between
    recurrent neoplasm and inflammatory or physiologic
    uptake."

    The article can be found at ccjm.org/content/73/12/1075.full.pdf

    PET/CT are becoming very common and I was surprised to hear that your insurance company would not pay. IIRC you had some uptake on your first PET which is not unusual but I would think you could make a case for seeing if it has changed since your baseline scan. The cost of a PET/CT where I live is under $2K retail and about $1600 under Medicare. Good luck and stay healthy!
    John

    insurance issues
    Luckily, my insurance carrier never denied any treatment that any of my doctors ordered.
    I know I had a PET scan pre or early-on in treatment, but after 6 years out, I am not having any scans.
    The one thing you have to remember is that if your insurance carrier is provided through your employer, they will not be receptive to preventive measures. They do not want to pay for prevention since, in my case, they might not be the carrier for treatment. My company changes medical insurance carriers every one or two years. Usually the insurance carrier is changed every January. I am totally surprised when the new carrier accepts my pre-existing condition at all.
    I think it is a moral outrage that a doctor on the insurance company's payroll, who is PAID to keep the insurance company's costs down, is determining whether a person needs tests or treatment! Sorry, I get a little carried away...

    But as stated before, the billing codes are usually the reason most people have problems with insurance payments.
  • meaganb
    meaganb Member Posts: 244 Member
    #23
    mls351w said:

    insurance issues
    Luckily, my insurance carrier never denied any treatment that any of my doctors ordered.
    I know I had a PET scan pre or early-on in treatment, but after 6 years out, I am not having any scans.
    The one thing you have to remember is that if your insurance carrier is provided through your employer, they will not be receptive to preventive measures. They do not want to pay for prevention since, in my case, they might not be the carrier for treatment. My company changes medical insurance carriers every one or two years. Usually the insurance carrier is changed every January. I am totally surprised when the new carrier accepts my pre-existing condition at all.
    I think it is a moral outrage that a doctor on the insurance company's payroll, who is PAID to keep the insurance company's costs down, is determining whether a person needs tests or treatment! Sorry, I get a little carried away...

    But as stated before, the billing codes are usually the reason most people have problems with insurance payments.

    Thought I'd throw my two
    Thought I'd throw my two cents in. I have never had a PET scan. I had a CT to diagnose the mass then a full body CT several weeks after the mass was removed. I switched ENTs and my new Dr ordered a brain/neck MRI 3 months after Rads and my oncologist did a chest x-ray. I think scans are important but I don't think we should get caught up in what tyPe they are. I haven't had a CT since Apriland unless I tell my Onco that I want one, he hasn't scheduled one until Feb which is when I had my first one. Just chest x-rays and physical exams until then. I have a friend who is a radiologist and when I told him about so many having PET Scans he said it isn't always necessary and I shouldn't worry about having one. I totally understand the desire to have one because we all want to be well informed and stay on top of any recurrence that might happen but I don't think we should 100% trust that a PET scan is the end all. I've read stories of PETs not picking up tumors at all or on the other end lighting up falsely and causing undue worry. I know it's hard because sometimes insurance companies don't make any sense. During my full body CT they at first didn't want to cover the neck part of the CT....everything else was fine( head, chest, abdomen) but they didn't want to cover the neck( where my tumor had been located!) eventually they did cover everything but I honestly did the scan before they approved it. I figured thatif they didn't payI'd rather go ahead and not have treatment delayed. Anyways...trust your Onco and ENT. I'm assuming you trust them and they are well trained and I think that if they are doing regular physical exams and even if they are ordering regular CT and/or chest x-rays you will be just fine. Tim, I know you have a strong faith. Just remember that Jesus has got you. There is no reason for worry! ( easier to say thanpracticesometimes!) Best to you!
  • hwt
    hwt Member Posts: 2,328 Member
    #24
    meaganb said:

    Thought I'd throw my two
    Thought I'd throw my two cents in. I have never had a PET scan. I had a CT to diagnose the mass then a full body CT several weeks after the mass was removed. I switched ENTs and my new Dr ordered a brain/neck MRI 3 months after Rads and my oncologist did a chest x-ray. I think scans are important but I don't think we should get caught up in what tyPe they are. I haven't had a CT since Apriland unless I tell my Onco that I want one, he hasn't scheduled one until Feb which is when I had my first one. Just chest x-rays and physical exams until then. I have a friend who is a radiologist and when I told him about so many having PET Scans he said it isn't always necessary and I shouldn't worry about having one. I totally understand the desire to have one because we all want to be well informed and stay on top of any recurrence that might happen but I don't think we should 100% trust that a PET scan is the end all. I've read stories of PETs not picking up tumors at all or on the other end lighting up falsely and causing undue worry. I know it's hard because sometimes insurance companies don't make any sense. During my full body CT they at first didn't want to cover the neck part of the CT....everything else was fine( head, chest, abdomen) but they didn't want to cover the neck( where my tumor had been located!) eventually they did cover everything but I honestly did the scan before they approved it. I figured thatif they didn't payI'd rather go ahead and not have treatment delayed. Anyways...trust your Onco and ENT. I'm assuming you trust them and they are well trained and I think that if they are doing regular physical exams and even if they are ordering regular CT and/or chest x-rays you will be just fine. Tim, I know you have a strong faith. Just remember that Jesus has got you. There is no reason for worry! ( easier to say thanpracticesometimes!) Best to you!

    PET
    I had a PET at onset and just had one 5 months post tx. I have to say I was surprised that my ONC said that was the last PET, from here on out, for 5 years, her choice is CT scans. I've trusted her this far and everything has worked out so I guess I will continue with her recommendation.
  • Greend
    Greend Member Posts: 678
    #25
    something that worked for my son
    Call your insurance company and when they deny your doctor's request then tell them "I want to speak to the doctor who is turning down my doctor's request" My son did this and it was approved in less than 5 minutes after numerous denials.

    Worth a try.
  • ratface
    ratface Member Posts: 1,337 Member
    #26
    Greend said:

    something that worked for my son
    Call your insurance company and when they deny your doctor's request then tell them "I want to speak to the doctor who is turning down my doctor's request" My son did this and it was approved in less than 5 minutes after numerous denials.

    Worth a try.

    It's a cat and mouse game
    And we are the mice. The good news is that the mice usually win in the long run. At three years post my last two scans have been denied. My insurance company uses, "The national cancer comprehensive network guidelines", which spell out the imaging guidelines for specific cancers. You can join their network and get access to the guidelines if you wish, it's quite simple. The problem arises if you are "asymptomatic", because according to the guidelines the only test recommended for followup is a figiggin chest x-ray. The insurance company will hang their hat here and punt the ball to you. This is the point where you request an appeal. My insurance company contracts with ENT's in the field who will review the case. This is where you bring up pertinent information about coughing and aspiration and trouble swallowing if applicable. This process will involve your nurse practitioner and doctor who will typically conference call with the insurance doctor. It's a huge waste of resources all the way around and a huge PITA but in most cases you will get them to approve a scan although the process takes months and endless letters and phone calls. Stay organized throughout as it does facilitate the fighting. I'm currently in a situation where the hospital did a scan that wasn't authorized and billed me for it. It's a constant battle and there is more than one cat. Be careful! meow

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