Insurance Claim Help

[SoonerMark]

Hello freinds, I've had a PSMA scan and the insurance company needs the procedure broken out between the Gallium 68 component and the PET scan. Does anyone have these costs separate they could share ? The facility which performed the scan could not separate the two. I'll use the ratio of your answer to provide the insurance an estimate of each. Thanks in advance for your help.

[tango65]

My understanding is that UCLA charges around $ 3000 for the PSMA ligand and they bill the patients for that a mount before doing the scans. They do not bill the patients for using the PET/CT machine and for reading the scans. Perhaps they charge the insurance companies for the use of machine and technical services but I do not have any way to know.

[SoonerMark in reply to tango65]

Thanks for the reply. There are two separate insurance codes which can be billed and they insist on having both. It may be because they will only pay for the scan, but not the contrast agent.

[tango65 in reply to SoonerMark]

I think that is the situation.

These are some links with info:

cms.gov/Outreach-and-Educat...

radiologytoday.net/archive/...

Only UCLA and UCSF are approved to do Ga 68 PSMA PET/CT and I believe is considered a whole body PET/CT. Outside UCLA and UCSF the studies should be done in a clinical trial and one may have to pay for the tracer.

[Tommyemily]

Obtain the price and code of a standard PET CT without PSMA and the difference between that amount and the total you were charged will be the additional cost of the PSMA (Gallium).Presuming the insurer is trying to wiggle out of the PSMA this method is most likely to give you the best result.

[Hidden]

I had a PSMA at UCSF. I had the codes which I used for a pre-cert prior to the scan. I no longer have them but UCSF was great about giving me the codes and cost breakdown. They might help you if you call. From memory, the Gallium part was $800. I also had a scan at UCLA however they did not break out the codes/costs. There is a member at prostateforum.org/ who has been very tenacious at getting the codes for the whole procedure; sorry, I don't recall his name. However he is very active in the group and if you contact the forum, someone will almost certainly be able to connect you with him. Good luck.

[SoonerMark]

Thanks for the info. The hospital I went to charges one amount, but I was able to get the cost of the PET/CT from them as an independent cost and will subtract from the total with the remaining being the tracer component.

At times, insurance companies can be difficult to deal with.

[j-o-h-n]

"At times, insurance companies can be difficult to deal with."

The freeking understated of the year. So far you're the first place winner. NOTE: First prize winner one week vacation in Oklahoma..... Second prize winner, two weeks vacation in Oklahoma....

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 09/20/2021 7:42 PM DST

[mrssnappy]

SoonerMark, did you get what you needed? I can dig up the billing for our PSMA and see if the codes are there if you still need those. We paid out of pocket at UCLA and I think they did break down the charges in two categories.

[SoonerMark in reply to mrssnappy]

Hi mrssnappy, I beleive what the hospital sent me should be OK, but you never know. Thank you for the offer, I appreciate it very much.