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CT scan versus PET scan-which is best?

jodil
Posts: 42
Joined: Nov 2017

My insurance company just refused my medical oncologist's request for my PET scan but approved a contrasting CT. I was diag w/ MMMT as well as colon cancer Oct 2017. Had pre surg contrasting CT done which ended up providing inaccurate info by indicating the uterine cancer was confined to uterus which turned out to not be the case. During surg the cancer was also found in 1 fallopian tube and 1 ovary and bloodwork indicating presence in thyroid so it's hard for me to have faith in the CT. Had the complete hyster. and a removal of a mass on colon. After healing frm surg a PET scan (approved by same insur co)was done to help determine next step. Drs. and tumor board decided to first go after the uterine cancer as that was the most aggressive. Completed 6 rounds of carb/tax 2 weeks ago. Was supposed to have the PET done this coming mon and just got the call yesterday that United Health Care refused approval of PET but would allow the contrasting CT. My oncologist's asst. spent 45 minutes on the phone w/ insur co. for a "peer to peer"/doc-to-doc discussion but still denied. I also called the insur co. and was told I should write a letter requesting a reversal of the denial. I have a nurse case manager thru United Health who told me there are 3 more ways to appeal starting w/ yet another phone call from my oncologist. Meanwhile it feels like more time is being wasted which i don't have. My belief is that the CT won't give the info necessary for my doctor to make the most accurate decisions regarding my tx. I am curious what opinions you all have are on the accuracy of CT versus PET and if anyone has had this experience w/ the insur co. How much more $ could the PET be?! They have already paid for so much already WHY won't they pay for a test that could end up costing them LESS by giving my doc more accurate info on how to treat me?! Thanks for any suggestions you have. Meanwhile my CT has been scheduled for one week.

Violet123
Posts: 26
Joined: Nov 2017

My insurance also denied a PET scan last week, so I am working on getting a contrast CT scheduled as I have just completed the 6 rounds of carbo/taxol in Jan, 2018, and 25 rounds of radiation this month.  The surgical oncologist had ordered the PET Scan to see how effective front line treatment was. When it was denied, his nurse called me and said he was OK with my having the contrast CT. The radiology dept did say when I initially had an order for the PET Scan that the areas where I was just treated for radiation  would light up with the PET Scan for several weeks after radiation treatment due to the effects of radiation.  So Maybe the CT will be more accurate in my case.

evolo58
Posts: 293
Joined: Dec 2017

I'm in a somewhat similar situation. My insurance company will not pay for a PET scan, but my surgeon feels the CT scan with contrast should do the job.

CT or PET scans are pretty darn expensive, so it's not like I have a whole bunch of options.

NoTimeForCancer's picture
NoTimeForCancer
Posts: 2599
Joined: Mar 2013

Personally, I had a pre-surgery dye contrast and a post treatment dye contrast.  In any event, I hope the link helps explains a little more of the differences between the two.

 https://www.diffen.com/difference/CT_Scan_vs_PET_Scan

jodil
Posts: 42
Joined: Nov 2017

this article was extremely helpful. I am going to quote from it in my appeal. Thank you! 

pinky104
Posts: 574
Joined: Feb 2013

I've had CT scans which I've had to have followed up by PET scans, so there must have been something additional the doctor was looking for in the PET scan.  I think the PET scan shows the detail a little more clearly, as I recall I heard somewhere.  In my case, the PET scans, as far as I know, didn't add any new cancer sites.  The report on mine was very similar to the CT scan report, as I recall. 

The first time I had a PET scan, in 2010, it was paid for my a local HMO.  The second time, last spring, it was paid for by AARP United Healthcare.  I don't know if my being stage IVb UPSC may have played into their approving it, or if how the hospital or doctor presents the case for it makes a difference, or if timing before or after surgery makes a difference. Maybe they're just getting stricter with their coverage approvals this year!

I decided to look up the charges for both in my Medicare statements from March, 2017.  The CT scan of my abdomen and pelvis had a charge of $1,187.00 of which Medicare paid $193.66 and my United Health Care paid $49.41 (I didn't go thru my United Healthcare statements, but they've always paid the balance on the Medicare approved amounts of what is left after Medicare pays their share).  There was an associated charge for the radiologist to interpret the scan of $200.  Medicare paid $90.89 leaving a balance on the Medicare approved amount to be paid for by United Healthcare of $18.18.  The charge for the PET scan was $4,500 with Medicare paying $1,032.38 and the balance for United Healthcare to pay of $274.34.  There was a drug called Fluorodeoxyglucose f-18 fdg that cost $280.00 with Medicare paying $210.74 and the balance of $56.00 for United Healthcare to pay.  The radiologist's charge was not listed on this Medicare statement, so it must have been charged on a later one (I didn't go looking for it).  To sum this all up, there are large charge differences between a CT and a PET scan, but the actual payments by United Healthcare are quite a bit less due to the fact that Medicare decides what each procedure should cost, then they pay 80% of that and leave the balance for the patient or other insurance to pay (United Healthcare in my case).  There may be other charges that I missed  on here (such as IV contrasts,etc.).  I had a lot of charges that month to wade thru, including an ER visit, so I can't guarantee I picked up everything.  Anyway, I hope this helps.

jodil
Posts: 42
Joined: Nov 2017

Thank you pinky fore taking the time to find all that information on cost! That is very helpful.

jodil
Posts: 42
Joined: Nov 2017

Thanks so much everyone for your responses! Much appreciated. I guess what I will do is have the CT scan, meet with the onc and then see if he will request a PET if anything looked questionable on the CT. Maybe THEN  insur will cover!! Meanwhile I will write an appeal and see if onc will do same. Thanks again.

pinky104
Posts: 574
Joined: Feb 2013

You're very welcome!

I just spoke to my husband about how United Healthcare had denied you the PET scan.  He suggested there might be another reason besides the one I mentioned as to why we had different experiences with United Healthcare.  Do you have a Medicare Advantage Plan thru United Healthcare?  We have a Medigap Plan F, their plan with the highest coverage.  It costs the most, but pays the best.  We have no copays for doctor,  inpatient or outpatient hospital bills, lab fees, x-ray fees, etc.  We didn't even know the plan existed until my husband lost his retirement coverage thru a previous employer, and they put us on an internet service that told us what coverage is best for each individual's circumstances. We are, however, responsible for getting drug coverage thru other companies, because Medigap plans don't cover drugs.  We were lucky that we lost coverage since that made us an exception to the normal rules for getting onto Medigap plans.  I probably wouldn't have been allowed to get on a Medigap plan if they had known that I had cancer previously.  The Medigap plans will be phased out in a couple of years, but we will be grandfathered into ours.  We just hope the insurance companies don't eventually decide to discontinue the plans for people who are already in them as their numbers dwindle.

I hope you can get somewhere with your appeal.  Good luck with everything.    

jodil
Posts: 42
Joined: Nov 2017

thanks for talking to your husband about my situation. That is good info to be aware of! I am 59 and up til Friday, had maintained my employment. I made the decision to retire and friday was my last day. I will maintain my current UHC insurance plan thru COBRA. I will likely start my disability paperwork this week but even if approved, would not be eligible for medicare for 2 years from approval, (at least that was my husband's experience). Thanks again Pinky!

takingcontrol58
Posts: 243
Joined: Jan 2016

Jodil,
My first CT scan was 2 months after my surgery, then 3 months after chemo then again after the 6th chemo.
These scans were performed by MSK and were always approved.

I stopped chemo at that point yet still had 2cm of tumors remaining.  So 2 months later, my integrative 
oncologist ordered a PET/CT scan which was denied by my insurance (I am not on Medicare). I appealed
but to no success. So I went back at looked at all the diagnostic codes that MSK had used when they
did my CT scans (which were always approved).  It turns out that they used 7 diagnostic codes, each of
which reflected sites where I had additional metastases.  When my integrative onc ordered the test, he only
used one basic diagnostic code for endometrial neoplasia.  When all 7 codes were resubmitted, the PET
scan was approved.  You may want to find out what codes your doctor submitted, as it may not reflect
the entire picture of your condition.  You want to make sure they are also adding the codes for your
colon cancer. I always figured if a PET scan was not approved for metastatic or a second cancer,
who would it be approved for. You have to be you own detective.

Also, a CT scan will show you if a lesion is identified on a scan.  You still have to
get a biopsy to confirm cancer.  A PET/CT scan will tell you if the lesion has metabolic
activity, it will give you the SUV value (standardized uptake value) ; the cancer cells
take up the radioactive tracer in the FDG contrast more than normal cells.

Takingcontrol58 

jodil
Posts: 42
Joined: Nov 2017

thanks so much for this info. I will call my oncologist's office tomorrow to find out what coding was used and ask for resubmission

cmb's picture
cmb
Posts: 387
Joined: Jan 2018

When I had to make an insurance appeal last year, I found it helpful to review the guidelines that my insurer posted for medical providers regarding what they would/would not cover for various diseases and treatments. I was able to reference a specific section from the relevant guideline in my appeal that supported the reimbursement of genetic testing costs and the insurer (Blue Cross) subsequently agreed to cover this claim.

United Healthcare has the same type of document that includes all of the evidenced-based criteria that are used to determine medical necessity for advanced imaging available at:

https://www.uhcprovider.com/content/dam/provider/docs/public/policies/clinical-guidelines/imaging-evidence-based-clinical-guidelines.pdf

The sections on PET scans are near the end of this document. I hope that you can find some useful information in this guideline for your appeal.

jodil
Posts: 42
Joined: Nov 2017

thanks cmb!!! I read it and found it very helpful. I will be siting some of the information in my appeal. 

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