CSN Login
Members Online: 4

You are here

Insurance Approval PET

dewdrs
Posts: 9
Joined: Jan 2019

Hi Eveyone!

Just wondered if everyone has issues with insurance approval.  Our doctor is having to do a peer-to-peer review to get approval for a PET-CT.

Is this just the beginning?  Anyone have similar experience or any tips to share? 

My wife is slated to complete a consolidative therapy with 4 cycles of DA-EPOCH-R plus 4 cyles of Intra-Thecal chemo and then finish treatment with a move into the stem cell transplant stream for an Auto-Logus Stem Cell Tranplant.  We are told this is the best chance of a cure for my wife's diagnosis of Triple Exressor Lymphoma.

Round 3 starts on Wednesday if blood work is a go... 

We would appreciate any feedback!

dewdrs

ShadyGuy's picture
ShadyGuy
Posts: 355
Joined: Jan 2017

and no problem to date. Just had a CT on short notice while in hospital.

Evarista
Posts: 250
Joined: May 2017

This does not surprise me a huge amount.  I know that within my own clinic (an NCI-designated cancer center), the doctors are of different opinions on how many and how often to do PET scans, particularly after treatment.  You do not say a what point her PET is scheduled.  My impression was that everybody gets one at the end of treatment.  Some people get them mid-treatment (I did not; I got a CT).  Some people get them 3, 6, 9, and/or 1 year after treatment.  I got those, but again, if I had been with a different HEM-Onc specialist within the group, I might not have. I am not due to get anymore.

FYI: Medicare & Blue Cross paid for them all, but I did have to sign "guarantees" for the follow-up one.  Good luck

dewdrs
Posts: 9
Joined: Jan 2019

Shady Guy/Evarista,

Thank you for yoru input!

Our doctor had a peer-to-peer review with the Cigna doctor and it looks like they will do a CT but not PET-CT.  NCCN Guidelines seem to hold up PET-CT scan as the tool for diagnostic and end of treatment and even restaging for agresive lymphomas.  Kind of depends on the sub-type it appears.  However, it specially states that PET-CT is more sensitive and specific than CT.  The worry seems to be that with repeat scans in too short of a time frame you could have false-positives.  Directive in most cases for repeat PET-CT appears to be nore more than one every 6 months.  Biopsy with Flow Cytometry and IHC is the gold standard litmus test. 

Doctor is following NCCN guidelines and restaging after 2 cycles for my wife's triple expressor lymphoma.

We'll be leaving for the hospital shortly...

dewdrs

Evarista
Posts: 250
Joined: May 2017

I had two.  One at 6 months was followed up with a CT and deemed "nothing to biopsy".  Second one was on my pancreas and followed up with MRI and endoscopic ultrasound biopsy.  MRI was a vague result and endoscopic procedure found "nothing to biopsy".  Another PET was ordered for 12 weeks later (why I had a 5th one):  no signal on pancreas. So...

This is a very dark rabbit-hole to go down unnecessarily and why some (many?) physicians do not want to be aggressive with PET scans.  Do note that positive signals on PET are cross-checked with CT or MRI...

dewdrs
Posts: 9
Joined: Jan 2019

Evarista,

Due to my wife's sub-type doctor wants to treat agressively and my guess is a PET-CT would be as much patient reassurance as it would be indicative of response.  There are, of course, NCCN guielines for determining response with a CT for Lymphoma so apparently it is sufficient for restaging because it is being scheduled now and we are waiting to see when to leave for hospital.  At least we are not in a hotel waiting...

We are certainly sensitive to false-positives.  Would not be good to have those...

Thank you for sharing your experience!

dewdrs

Scubamom for two's picture
Scubamom for two
Posts: 18
Joined: Apr 2018

Hi dewdrs,

I think each time my insurance approved the PET-CT's, they had to have a peer-to-peer consult.  My insurance co. also held up a necessary Neulasta shot for several hours one time due to their arbitrary peer-to-peer consult requirement and that forced me to delay starting my third round of DA-R-EPOCH by a day.  A supervisor at MDA actually finally just approved the shot at close to their closing time that day before my insurance fully approved it and I was relieved because I had literally been there all day since very early that morning getting a bunch of scans and a new PICC-line placed...

As you probably recall, I was also treated at MDA.  I had an initial PET-CT prior to beginning my treatments, additional PET-CT's after my second, fourth, and sixth rounds of DA-R-EPOCH and related treaments.  I also had a PET-CT at my first three-month post-treatment check up, but since then I have been getting CT's of my chest, abdomen, and pelvis at quarterly intervals.  My Dr. told me that insurance companies don't like to approve the PET-CT's for post-treatment survellience because they are supposedly more expensive.  I have read some research studies that indicate they are not as necessary post-treatment though.  Anyway, I had a total of 5 PET-CT's and all were paid for by my insurance company.  I found that the folks at MDA navigated things with my insurance company very well and there were only a few time delays in getting things approved.  I hope things go smoothly for you and your wife as you continue on this unplanned journey!

 

Cheers,

Diane   

dewdrs
Posts: 9
Joined: Jan 2019

Scubamom,

According to our doctor's nurse, the request for approval just landed on her desk this week and she submitted as soon as she received.  However, the contractor for our insurance, Cigna, said they received it that same morning while the appointment has been scheduled for several weeks after our last doctor consult.  We are not sure where the ball got dropped but the insurance company certainly has plausible deniability since they use a contractor and I would be willing to wager the contractor has incentives to deny expensive imaging.  While our doctor surely wanted to see a PET-CT she is settling for a CT after the peer-to-peer so we will be asking some questions. 

You can be sure we will follow up on any future imaging requests at least a week prior to make sure the approval is received timely or if a peer-to-peer is required, our doctor will have time to schedule with the insurance company doctor prior to the scheduled appointment.  I would like to see a PET-CT myself, so that we can see the metabolic activity, but that won't be the case this time.  We have researched the criteria to determine Complete Remission, Partial remission, etc. so we will be eager to see the results.

We surely appreciate you sharing your experience and your positive sentiments!

dewdrs

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3116
Joined: May 2012

dew,

Through nine years of Hodgkin's treatment and follow-up (I still get HL testing annually, and am told this will be for LIFE), and three years with prostate cancer, I have never yet had any issues (known to me personally) with getting any form of scan or test approved.   I guess I've had three PETS, and easily 10 CTs during this time.  Too many types of blood panels to reconstruct. Biopsies fo both nodes and the prostate gland itself.

Most likely your snags are particual to your insurance.  If she is old enough for medicare, that also complicates things, as they debate who pays what.  I was a vendor in the VA system for about a year, and am myself a vet who in the past used the VA for primary care, and that also massively confuses billing and authorization (I was not using the VA system at all when treated for my cancers).

Your wife's diagnosis is aggressive and complex. This takes her treatment plan out of the de facto cook book responses that oncologists ordinarily defaut to when cases are more straingforward. This also throws the insurance providers off kilter.  There may not exist standardized insurance protocols for what she has, or how to approach it, so the providers resort to ad hoc responses.  Such is the case with my own HL. While indolent, it is very rare, and has had little treatment research directed toward it.  Ergo, doctors treat it as if it were conventional HL, which it is not. But, luckily, these treatments usually do work for my disease.

Overall, it sounds like your wife's care is premium quality and meets or exceeds all Best Practices.  I would not be very concerned, based on the specifics you have submitted here.  By "not very concerned," I mean to the treatment responses she has received.  The disease itself is serious, and any normal individual would be given to worry and due concern.

dewdrs
Posts: 9
Joined: Jan 2019

Max,

Thank you for your perspective.  I agree the care she is receiving is within the standard of care.  There is debate on the timing of a PET-CT and with the enhanced CT she received they were able to determine she is responding to the treatment since her involved lymph nodes shrank considerably although a lesion in her spleen did not show much response.  Overall very positive news and her hematologist/oncologist was able to dial up her chemo dosage.  She will receive a PET-CT prior to being released to the Stem Cell Transplant team so that will allow them to determine if she has achieved a complete response or not.

We had a consultation with the Stem Cell Transplant team.  It will be challenging but we feel pretty positive.  She has had a lot of information from caregivers in the hospital about the usual and customary side effects and she will be diligent in the self-care portion of the regimen.  Even with the serious and agressive nature of her lymphoma she has a good chance for cure.

Fingers crossed!

dewdrs

Max Former Hodgkins Stage 3's picture
Max Former Hodg...
Posts: 3116
Joined: May 2012

I am delighted with your update, and am hoping for good results for the both of you,

max

Subscribe to Comments for "Insurance Approval PET"