After being turned down twice for the Axumin scan after BCR for pre-authorization at the peer-to-peer review level with my MO and the head of the OHSU Knight Prostate Cancer Center my docs and I are fuming! I have called other prostate cancer oncology groups who have had the same experience. My insurance company is Providence Health Plans.
They said they flat out won't cover it, even though it's FDA approved specifically for this condition. They won't even cover PET scans at all for prostate cancer. They consider it an inappropriate diagnostic tool. This is approved by the FDA, NCCN Guidelines for PET scan for suspected BCR and others.
This is true of other insurance companies as well and will continue to be more common as new diagnostics and treatment modalities are approved.
I have come to believe that patients need a non-profit advocacy group with the ability to take legal action against the insurance companies, if needed. Is there such a group? Patients with many conditions fall in these gaps without recourse.
Pitchforks and torches time!