I'm new here...and I appreciate anyone's insights for my question. I'm going to UCLA for the PSMA PET scan, and just found out that Medicare does not yet cover this cost ($3300). Does anyone know when Medicare might cover this? UCLA tells me they will reimburse me if-when this happens.
I thank you very kindly for your thoughts.
No one has that crystal ball, unfortunately.
Thanks Tall_Allen, that's largely what I thought. I figured it doesn't hurt to ask, so I appreciate your reply.
Do u have a secondary insurance? My dad lives in Michigan and for a while Medicare
Refused to pay for the test but now they decided too? It took a year for them to realize it did help people with cancer I don’t know if it’s state by state sorry
Hi Olivia, yes I have a Medicare supplement. But I’d assume it won’t kick in unless Medicare itself covers a given procedure. The good news here is that Medicare may (should?) eventually cover this and I’ll get reimbursed. So it’s all good. Medicare has helped me with almost everything so far, so no real complaints.
Can you provide the hospital where I can get this test in Michigan. Thank you.
Hello my Dad got his test at Troy Beaumont he has Medicare and HAP I know it’s an expensive test One year he had it done the following year they weren’t doing them anymore but the radiologist technician told me it was due to the fact that it was super expensive and a lot of insurances didn’t wanna cover it but then now they decided that insurance or my dad‘s insurance would cover it too so they brought it back and people are getting the test done and most insurances should be covering at I hope that helps
Hello, This is great information. I just saw a PA (Dr. Howard's ) at Beaumont and was told they do not do the PSMA scan but wanted me to do the Axumin scan. I have had three previous scans two at the University of Indiana and one at University of Heidelberg. I think the CD's of these and another at Beaumont makes things more precise. I am going to challenge them tomorrow. Wonder how this will work out. Thank you.
Actually I’m sorry the PSMA is not offered the Axumin scan is I totally misunderstood.
They only have that scan at UCLA we won’t get it here for a while I asked my dads urologist and he didn’t even have a clue what I was talking about? I saw this on the Today show months ago but again No Beaumont doesn’t offer it I misunderstood your question they only offer the regular imaging and the Axium
How do you like Dr. Howard? My dad saw him but we stopped going.
Hard to like
Who is your dad seeing now?
We are only seeing a urologist he is on xtandi and gets his blood work and xgeva shot monthly and every three months eliguard. Howard wanted to start chemotherapy 2 years ago but we felt it wasn’t going to cure my dad and he was also afraid of the treatment so we take the pills and his PSA remains low. He took a break from xtandi because of the side effects and his PSA still remained low for 8 months then started to rise and he’s back on xtandi. But my dad turned down the chemotherapy with Howard and I’m glad we did.
Just had one last week at USCF Medicare covered it. Good luck !!
Thanks TLCAM12. You had the Ga-68 PSMA scan at UCSF? As part of a trial, or simply in the facility as outpatient? If yes you had Ga-68 that was not part of a trial, could you send me contact information?
UCSF Urology dept. I am seeing Dr Peter Carroll, he is a world renowned MD with all the latest technology at his disposal.I’m waiting for a surgery date and will be in a trial where they use PSMA Bio Luminance injected into my abdomen the day before surgery, this will ( just like the PSMA PET scan ) attach it self to any PC proteins and actually illuminate that abdomen cavity to help better get all the Ca. They are the only people on the planet doing this currently. My PSMA PET scan was done as an outpatient. I don’t have their contact info to share. I just went to UCSF Urology dept and made some calls. They are very friendly and was very easy to get in. I have Medicare and a great supplemental and so far it’s all covered. Good luck !!
I had a scan at UCLA last week and the whole billing situation is pretty opaque. They gave me a Medicare disclosure form for the total charges of $22,339.25, and they collect what they estimate as $3300 for what Medicare won't pay. I believe that when they bill Medicare they either get paid for some of those extra charges, or they don't and aren't allowed to bill me, but I'm really not sure. They said that if Medicare does pay the whole thing, they will refund my $3300 less any deductibles. Since this $3300 is more than the $2800 I paid 18 months ago in the clinical trial, I suspect that they cover their costs with the $3300.
Here is the exact wording for the check box they want you to check on the disclosure form:
"I want the D. PSMA-FDA Approved listed above. You may ask to be paid now, but I also want Medicare billed for an official decision on payment, which is set to me on a Medicare Summary Notice (MSN). I understand that if Medicare doesn't pay, I am responsible for payment, but I can appeal to Medicare by following the directions on the MSN. If Medicare does pay, you will refund any payments I made to you, less co-pays or deductibles."
Thanks for the details, TeleGuy. What you're describing is consistent with what I was told over the phone. Appreciate your taking a moment for me.
My TO told me that PSMA will be covered after the new year.
Nalakrats, we are in the process of trying to decide on a Supplemental plan to go along with the standard Medicare... we will NOT go with Medicare Advantage thanks to the warnings from all the good people on this site! Hubby will be starting Medicare this Dec. so we really need to get the best Supplemental plan to help pay what Medicare doesn't. Since you've been dealing with this for 13 years, would you be so kind to share what Supplemental plan you have and if you're happy with it?
Hubby's PSA has risen the last 3 times and will have it done again at the end of this month... praying it hasn't gone up again! The Dr. said it might be time to add a pill?? but wants to get an Axumin scan first (he had an Axumin back in Aug. 2018 when his PSA rose to 3.08 and it showed 1 Pelvic Lymph Node that can't be radiated due to it being in the same field that he already had 39 radiation treatments. We really want to get a PSMA, since it would show more at a lower PSA, but have to wait until it's available here. He's been <0.01 PSA & between <1.0 & <10 Testosterone since 11/19/18. He had an Orchiectomy Jan. 2019. His last PSA's done every 3 months have been 0.03, 0.12, then 0.22 with T. of 14--so that's starting a fast doubling time we don't want to see. It's concerning with his prostate cancer history, but PSA is still too low to show up on Axumin and PSMA not available here yet (all standard Bone scans & CT's are always clear, no surprise with prostate cancer). I say all this because he may have to start meds that could be very expensive, thus why I'm asking for any help on which would be the best Supplemental to help us--we will be moving to Ocala, FL for his retirement. Any names of good MO's that deal with PC in that area would be a GREAT help also!!
Seek a Medicare supplement not an Advantage plan. Plan F I think . All of these plans are the same controlled by the government . Look into the high deductible plan. These plans are not guarantee issue and you may not find a company to sell this to you because of pre-existing conditions. Also, a supplement is usually only offered with pre-existing at age 65 including pre-existing. It is annual election period now and the Advantage plans must take you. Shop these plans. There can be a big difference in cost and benefits etc.
Just realized he is turning 65 this December and should be able to get a supplement as it is offered at this time. Start this process asap since you would want it to be in affect ASAP. Call his presence insurance company and see what they have to say.
The consequence of what lewicik said is this: choose your supplement plan carefully because when you first sign up, it's "by right." If you wish to change plans later, they can deny you based on your pre-existing condition. I have an Anthem plan that my broker recommended and I don't think they will be going anywhere anytime soon and leave me in the lurch.
Each to their own situation, wrt which Medicare plan is right…but just to chime in here with my own:
I had the Plan F for a few years until the premiums starting going thru the roof. This was the the zero-deductible Plan F, and the projection is that premiums will continue to rise dramatically. I do advise strongly against this choice; it will eventually disappear altogether as everyone continues getting priced out on it.
There is (IIRC) a high-deductible Plan F, but one may also wish to consider the low-deductible Plan G, which for me was the best option overall, and it’s the closest thing to the zero-deductible Plan F: good premiums, the only deductible is the Part B deductible, and otw covers everything that Medicare itself has approved.
My understanding, again IIRC, is that you can get guaranteed issue if this is your initial signup with Medicare; I did so w/o problem, and underwriting was not needed (i.e. my pre-existing condition was a non-issue). After that, you can also get GI during Special Enrollment (or is it Election) Periods, one of which just happened (at least in my home state, anyway). Again, no underwriting with this.
Now I’m not an insurance broker, so I could have all of this wrong. I decided to get a broker that I liked and trusted to help navigate all of this; it can be rather confusing. Having a broker does NOT raise your premiums; they make $$ from subsidies paid back by the Supplement (or Advantage, etc) plans themselves.
Lantheus issued a press release on 11/22/21 stating that Medicare granted Transitional Pass-Through Payment Status for Pylarify (piflufolastat F 18) injection effective January 1, 2022 which will allow Medicare to provide an incremental payment for PET-CT scans done with PYLAEIFY in the hospital outpatient setting. Not sure what is meant by incremental payments or how much of cost will be covered.
If your insurance plan says what services are covered, you can check with your broker to see exactly what you qualify for. If Medicare initially does not make such coverage, there is no point in explaining anything, otherwise every broker or insurance agent will work that way (go into the situation and approve the terms individually). There are some screening services that are not covered because it's not a treatment but an examination. Medicare Supplement plans Florida 2023 medigap.com/medicare-supple... may cover these, but you have to pay for the insurance yourself and have two insurances for such.
Medicare covered for second PSMA scan
Recent PSMA (Pylarify) PET Scan…. Covered by Medicare.
Medicare will pay for PSMA PET/CT Studies.
Cost of PSMA pet scan
Medicare Prescription Drug Coverage
