Does anyone have reccomendations for next steps? Currently inquiring about cash price of scan
Psa recurrence. BCBS anthem denied au... - Advanced Prostate...
Psa recurrence. BCBS anthem denied auximin scan
Written by
Vern54
To view profiles and participate in discussions please or .
Read more about...
33 Replies
•
There are clinical trials where you might be able to get even better scans for free. Recurrence after what therapy? Where are you located?
Total prostatectomy last August. Psa never went away still climbing. In the middle of California
UCSF and Stanford will be participating in a trial of DCFPyL PET scan, but they haven't begun recruiting yet. City of Hope and Tower Urology in LA have begun recruiting. Contact details below:
clinicaltrials.gov/ct2/show...
Is there any point in fighting the insurance. It’s fda and Medicare approved. Why can’t I have this. I’ve paid my health insurance for decades
Of course you can try, or with a day's travel you can get the better scan for free. Up to you.
I agree with TA. I am getting mine done in a week from now at NIH, Bethesda and it’s free. While you sort out your options, just call them and hopefully they will put in a waiting list.
in reply to Tall_Allen
HI Tall Allen
My husbands PSA has gone up from 1.14 to 2.15 Dr Oh at Mount Sinai wants a bone scan and CT scans of chest, abdomen pelvic area. I asked about AXUMIN scan. Have not heard back yet. What scan (IYO) is a BETTER scan to have?
Tall_Allen in reply to
To make what treatment decision?
in reply to Tall_Allen
You mentioned there are better scans out there than the axumin scan when someone posted that their insurance company would not cover the axumin. My husband needs to do some scans. Jump in PSA. I was asking if you can be more specific on what scans are the better choices?
Thank you
Tall_Allen in reply to
To make what treatment decision?
in reply to Tall_Allen
Well we do not know yet. My husband was diagnosed at end of 2015. Had 40 radiation txs. Thought he was done and cured. Was on Lupron injections. 1 year later his PSA began to rise. CT scans showed no bone mets. I requested axumin scan and there it was. It had spread to pelvic area and retroperitoneal. (Drs feel it may have been there prior to his prostate cancer detection but who knows) Had radiation directly to those two areas and added Xtandi. PSA on the rise again after 10 months of Xtandi. Dr Oh wants a bone scan and ct of abdomen, chest and pelvis. I was wondering about axumin scan bc Im thinking it is a better scan. someine here mentioned being declined for axumin scan and you responded by suggesting “a better scan”. I am wondering what scan is better than the axumin scan? I think the dr’s approach right now is probably correct and if there is nothing they can see on ct scans then I go with axumin. What is your opinion?
Tall_Allen in reply to
A scan is only a good idea if there is something different you might do if you see one thing or if you see a different thing. I think Dr Oh is interested in the number of metastases on a bone scan/CT (but not on another kind of scan) because chemo or Xofigo may be useful in that situation. If there are 4 or more distant bone mets, chemo may be a good choice. If there are no visceral mets but only bone mets, Xofigo may be a good choice. Different scans are approved or investigated for different purposes.
in reply to Tall_Allen
Thank you so much for your response! That makes sense to me. I may need to reach out to you again after March 20 when we receive scan results. Thank you again
Tall_Allen, I've been reading about the various new radiotracer scans for recurrent PCa, and have narrowed them down to a choice between Axumin and DCFPyL PET scans. I had prostatectomy in 2012 and BCR in 2015. PSA is increasing very slowly, fortunately -- now 0.45. Time to try to find out what/where it is and seek treatment. I haven't found good comparisons between the two. Do you have any references or opinions on pros and cons of the two scans for my situation. Thanks.
Hi Tall_Allen,
If my PSA level was 0.05 Feb 20th why the oncologest will send me to PET scan before my next PSA test March 19?
What is you advice?
BC recurrence because: PSA from < 0.03 (Oct 2018) to 0.05 (Feb 2019). Ultra sensitive PSA < 0.008 (Oct 2018) to 0.020 (Jan 2019) and 0.030 (Feb 2019).
Preparing myself emotionally for 6 months hormonal injections combined with SRT, will see Radiologist in 3 weeks.
A PET scan would be pointless. At 0.03, your PSA is too low to have SRT unless you had adverse pathology.
I agree with TA. I did my SRT at .07 and it failed. I only did the prostate bed and no adt. If I had to do it allover again, I would add adt in addition to SRT to the whole pelvic nodes not just the bed.
Go back to the insurance company and appeal their decision. Get your physician to support this and point out why this scan is medically necessary. Emphasize to the insurance company that if there are small mets that can be picked up on the scan now that they'll save a ton of money treating the small mets versus waiting until they become larger and cause even bigger problems. Never give up with insurance companies. Ever. The squeaky wheel gets the oil, especially with strong advocacy from your physician.
Here's my post that two months ago....
As many of you know, I had two oncologists fight with my health insurance company (Providence Health Plan) up to the peer-to-peer review level and were turned down flat. Well, the insurance company was no match for my wife!
She went to the final step of filing a "grievance appeal". She and I put together every piece of literature we could find from the FDA to the NCCA and numerous other professional organizations and publications that clearly showed that the Axumin scan is the "standard of care" for PCA BCR after primary treatment. We then made it clear in the accompanying written explanation that all of this evidence clearly shows this diagnostic imaging technology to be a widely accepted standard of care and that denying insurance coverage for this treatment was negligent and their guidelines were clearly outside the norm.
We did not threaten legal action but I am sure their lawyers said "Pay the man!" The day after we sent the appeal, I received a call from their grievance committee telling me that prior decisions had been overturned and that it would be covered, that they would immediately send the pre-authorization to my oncologist. I had the scan yesterday and I am awaiting the results.
This may not be the way all such claims go but it is an incentive to never give up! Thanks to everyone here for your thoughtful responses to my previous post about this. I hope that everyone will be somewhat heartened by this story because, we had little or no hope that the decision would be overturned and yet it was......so, never say never. Keep up the good fight!
Recommendation:
Take them them to the mat!!! Follow-up with a Peer-to-Peer review between your MO (more than one is better and should be very knowledgeable about this application for the Axumin scan ) and the BCBS doctors. If they still deny the claim....
File an EMERGENCY GRIEVANCE APPEAL. Copy THE FDA approval for this application, copy every article from reputable medical journals that state this is (or must be) the standard of care, comb through ncbi clinical trail results to include, quotes from MO's at major reputable prostate oncology departments at teaching hospitals about catching mets early and extending patient survival by changes in treatment plans. Make sure your sources are solid and reputable within the overall medical oncology and nuclear medicine community.
Be sure that to include in your "THIS IS THE STANDARD OF CARE FOR THE DIAGNOSIS OF UNDETECTED METASTASIS FOR THIS CONDITION AND YOUR PROTOCOLS DO NOT MEET THE STANDARD OF CARE OF THE REST OF MEDICAL PROFESSION AND CHANGES IN COVERAGE FOR THE AXUMIN PET/CT SCAN BY OTHER MAJOR HEALTH INSURANCE COMPANIES 9IN IDENTICAL CASES. THIS IS MATTER OF MY SURVIVAL AND YOUR LIABILITY."
The chances are that they care more about their liability than the small amount they will pay out for the scan. Be sure you meet the FDA approved criteria before you take this last step.
It worked for me and I hope it works for you! Have a family member or friend help you compile the information and write the grievance letter to be sure it is as rock-solid as possible. Good luck and let us know what happens.
Love your post! I am having my Auximin PET scan this afternoon. It was initially denied, but after peer-to-peer review it was approved. I have Horizon BCBS.
Was told that the Auximin alone is $4500. My OOP is 20%.
Does anyone know if , ' Ordinary Medicare', pays for this scan?
Appeal that insurance denial!
They denied it as not medically necessary. I will appeal. Your responses and encouragement help more than you could know
I did almost the same things that dmt1121 did, when Cigna Insurance denied the Axumin scan for my husband and after a second peer-to-peer with his MO and the Cigna TOP Dr. was done (with all the documentation dmt1121 described) it was finally approved! It found a pelvic lymph node that no other scans could find! What is your current PSA? If it's not at least 2.0 the Axumin probably won't show anything yet, our MO said 2.0 or higher is best to find things. I pray you can get approval!
I called the appeal company personally and got to a person who could make a decision and it was approved the next day . It’s about 6000 without ins ... good luck
It’s currently 2.4. Up from 1.8 last month
I had an Axumin scan May 2018 and I will have another one May 2019. The scan will be covered only if there is at least one year between scans. I have horizon BC/BS
Not what you're looking for?
You may also like...
Advanced recurrent PCa, rising PSA, 2 negative PSMA PET Scans
I have had rising PSA. During the summer of 2020 my PSA was 2.5, so I had a Ga68 PSMA PET scan at...
Aetna denied request for PSMA scan
for the PSMA scan. Does anyone know how much it would be out of pocket to have this
scan done. I...
Auximin Scan Effectiveness - Bone vs Soft Tissue
mention bones.\\" diller
Does anyone have any comments or thoughts or info on Auximin scan...
PSMA Scan with PSA<0.006
Seeking opinion of members
regarding utility of psma Scan with Psa <0.006 since 2 years .
I had...
PSA rising but scans clear
Dutasteride increases PSA Doubling Time after PSA Recurrence
LOW PSA BUT CT SCAN PROGRESSION
Is it PSA recurrence or not...
Newest PSA/NEWEST AXUMIN PET SCAN...STABLE 
