Axumin PET scan denied by Blue Shield

[FootballMom805]

My husband, John, is 49 years old. He has prostate cancer that has metastasized to his bones. He had a radical prostatectomy two years ago. We are currently being seen at Stanford Medical Center. Our insurance, Blue Shield, has denied Stanford's request for an Axumin Pet Scan, despite several calls and a peer to peer call. We were told it's because John is terminally ill; there is no cure for bone cancer and this is the natural progression of his illness. I've reached out to Axumin Support line but have not received a callback. We are meeting with our Stanford cancer team in 3 weeks to discuss what our options are. Has anyone had this same problem with their insurance? Any advice would be greatly appreciated!

[Tall_Allen]

To justify a test to insurance, it has to be decision-based. What decision are you trying to make based on the Axumin scan?

[billyboy3]

Please provide us with more information, history, psa scores, gleason and other tests, medications etc.

At only 49 he should have a long time to live. but you need to get details and generate a plan-which is what the med team will provide, which you can then bounce back to the brains that are on this site.

There is no cure now, so the game plan is one of buying him as much time as possible, perhaps many years yet, so good luck

[Longterm101]

Where do u live ?? NIH might be able to do one under a clinical trial

[Hawk56]

The two scans, C11 Choline and Aximun are FDA approved for recurrent PCa and are part of the NCCCN guidelines for imaging.

As Tall Allen says, what is the purpose, contact your insurance company, cite the purpose, identify sites of recurrence, let them know the scan is approved by the FDA for recurrent PCa and is part of the NCCN guidelines for imaging.

There is no cure but that is not the issue. Today, there are many FDA approved treatment regimes for treating advanced PCa which extend the lives significantly of people with the disease.

More information on your husband's clinical data and treatment history will help this group in providing information to help you and your husband and his medical team.

nccn.org/patients/guideline...

Spend some time reading this as it relates to your husband's specific PCa clinical data and disease state. It can help you in your discussions with your medical team and insurance company when framing your appeal.

Frankly, their reasoning sounds like "hope she'll go away..." Many people on this list will tell you that after the first denial, a well reasoned argument with supporting facts results in the insurance company authorizing the treatment. Mine tried to deny a C11 Choline scan, when I sighted the NCCN guidelines for imaging and my recurrent PCa along with the purpose and its impact on treatment, they backed down.

This group can help, with more information.

Kevin

[Shanti1]

Aetna originally denied our Axumin PET, even after "peer to peer". We went through the appeals process and sent a letter with scientific papers documenting efficacy. We made sure to point out why it was medically necessary and the potential harm that could come to my husband if it was not approved, indicating a potential legal issue in their hands down the line. They approved the scan.

[6357axbz in reply to Shanti1]

Nice

[blueCello]

Yes, my husband was denied the Axumin scan despite his radiologist requesting exactly that. We had to pay up front and then I fought like a tiger questioning why they would veto an intelligent doctor's request for the way they want to treat their patient. Eventually, I won with Healthnet HMO. It is very expensive; I think $7,000 in 2018. Other scans do not cost nearly as much.

[Mauvemood]

Coverage for test are usually driven by Medical Policy. Contact your insurance company and request a copy of the policy governing payment and the medical necessity requirements that were used to deny the coverage. Read the policy carefully to see if there is any type of individual consideration that can be made. Always, always, always appeal the denial of a service and work with your physician to provide the necessary documentation to meet medical necessity requirements as set forth in the medical policy. Was the service submitted with vague or an incorrect information?