Axumin Scan coverage on Medicare Advantage?

[DenDoc]

I have a new met in my mediastinum detected on a PET Scan with FDG tracer(the least sensitive). My ordinal mets were in my lungs. A second opinion urologic oncologist recommended getting Axumin scan for better idea if this is oligometastasis or not.

Problem is that I am in a Kaiser Medicare Advantage Plan and would need to convince the bureaucrats that they should pay for the Scan. Has anyone been successful in Medicare Advantage, especially KP getting coverage?

I am in Denver. Nearest Axumin is in Salt Lake City.

[curt504]

Hi, I can't help with you exact question, but I do have experience saving money on medical services and tests. There's a near secret system of patients buying the same test for cash at huge discounts vs using a prescription and running the payment to the service giver via insurance.

For instance for 10 yrs now I've bought my own blood tests from lef.org today the PSA test is $24 (its on sale) but I bet their non sale price is LESS than your co pay. That doesn't make sense does it, its via LabCorp same as your Dr prescription so there's a criminal racket going on (my view).

I had an elective procedure done, prior I called a medical services negotiator and he found me a procedure "mill" in the burbs for $1800 cash but insurance price $20k. Yup thats how it worked.

I suggest you do several things in parallel:

- call the local imaging places (not hospitals) and ask what their cash price is, no insurance filing. Hang on the phone and say "is that the best you can do?". Hang a bit longer and ask if theres someone with authority for even lower pricing.

- after you call all the local (and remote) imaging providors you'll have a sense who will drop even more. Then focus on that providor for best pricing.

- In parallel google: medical services negotiator -your city-

Then enlist them to get you your service for the best price.

I've found that our medical services consumption is almost entirely cash out of pocket. Our insurance has turned into emergency / catostropic care. I can find services for less than the co-pay almost all of the time.... so why bother with Insurance except for them to track our out of pocket, so I just send in bills I've paid, they pay nothing. Some day I'll hit the max out of pocket and hopefully something will kick in. I'm not counting on it.

Best of luck and please report back how you ended up getting your test.

BTW what is the exact description of the best scan test for METs?

[Hidden]

Good luck with your insurance battles. I signed up with Medicare Advantage only to be diagnosed with gleason 8 PC seven months later. I had to spend hours on the phone with the insurance company just to get a freakin' eligard shot after they dragged their feet for weeks on the approval. I got out of cheapskate mode and now I am on Medicare Supplemental Plan F. I don't need referrals, I'm not confined to a network, and I can actually select my own care providers, including a very good chiropractor.

[PETSup]

Im a Nuclear Medicine/ PET Supervisor we’ve offered Axumin for one year now. When it comes to insurance we have found there are a list of companies who still consider it investigational and will not reimburse for it even with an authorization. Patients must meet criteria so the insurance company will pay for it. Two consecutive rising PSA following “failed” treatment (lupron injections, brachytherapy, radiation, seed implants or prostatectomy) most hospitals and Radiology companies will not schedule you unless you’ve met this criteria. It’s is beneficial for those Patients who do as it will help your physician determine progression in a possible reoccurrence in prostate cancer. Currently I know Simonmed if offering this for 5700.00 unless you have an Insurance that is currently paying for this. I will lost a list of insurance companies for you another day plaease check back.

[PETSup]

Im a Nuclear Medicine/ PET Supervisor we’ve offered Axumin for one year now. When it comes to insurance we have found there are a list of companies who still consider it investigational and will not reimburse for it even with an authorization. Patients must meet criteria so the insurance company will pay for it. Two consecutive rising PSA following “failed” treatment (lupron injections, brachytherapy, radiation, seed implants or prostatectomy) most hospitals and Radiology companies will not schedule you unless you’ve met this criteria. It’s is beneficial for those Patients who do as it will help your physician determine progression in a possible reoccurrence in prostate cancer. Currently I know Simonmed if offering this for 5700.00 unless you have an Insurance that is currently paying for this. I will lost a list of insurance companies for you another day plaease check back.