Medicare will pay for PSMA PET/CT Stu... - Advanced Prostate...

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Medicare will pay for PSMA PET/CT Studies.

tango65 profile image

Good news. Medicare will pay for Ga 68 PSMA and for the Pylarify PET/CTs.

This is the link to the document from Medicare. Search for Ga 68 PSMA PET CT and Pylarify , I believe in pages 53 , 57 and 62 of the pdf format of the document (group 10 and Group 16).

cms.gov/medicare-coverage-d...

You could also call UCLA and inquire. UCLA Nuclear Medicine Scheduling 310-794-1005. (Use option 1 ). UCLA is not charging the $ 3,300.00 anymore and it is billing Medicare and secondary insurances for part B.

It seems that the approved Medicare payment will be $ 5,224.00 for the Pylarify PET/CT. The price without insurance is around $ 21,000.00.

People with Medicare part B and without supplemental insurance will pay 20% of the $ 5224. People with Medicare Advantage or other supplemental insurances will pay nothing or around $ 220 depending on the insurance they have,.

38 Replies

Thanks

This is great news.

That's good news, because as Medicare does, slowly does commercial insurance.

I had a PSMA on Sept 1st at Northwestern. Medicare approved the payment for it today. I have a follow-up scan scheduled for next Monday so we’ll see if that goes through a little faster.

tango65 profile image
tango65 in reply to ChicagoJ

I assume it was a Pylarify PET/CT. Is it correct?

ChicagoJ profile image
ChicagoJ in reply to tango65

Yes it was. I can’t see the details yet on the amounts that they are paying. For the Axumin that I had earlier, Northwestern billed about $22,000 and Medicare (and my supplement) paid about $6000. I paid nothing. I think this will be approximately the same.

tango65 profile image
tango65 in reply to ChicagoJ

The local cancer center charges $ 21,700.00 but Medicare will reduce the payment to $ 5224 according to the company making the Pylarify. I will have to pay 4% of $ 5224, which is much less than the $ 3,300 I used to pay at UCLA.

This is great news! Do you or does anybody out there know of the 3-scan (lifetime? yearly?) limit on PET scans by Medicare? I've had 3 since going on Medicare and I wonder if the next one will be a hassle to get approved.

JPnSD profile image
JPnSD in reply to TeleGuy

Are you talking any PET scans or PSMA?

tango65 profile image
tango65 in reply to JPnSD

Ga 68 PSMA and 18F DCFPyl (Pylarify).

TeleGuy profile image
TeleGuy in reply to JPnSD

There's supposedly a 3 scan limit for PET scans (regardless of type). It was expanded from 2 to 3 around 2011 I think it was.

tango65 profile image
tango65 in reply to TeleGuy

I never heard that there is a limit for PET/CTs for cancer diagnosis and follow up.

TeleGuy profile image
TeleGuy in reply to tango65

Here's a quote from Radiology Today in 2015 challenging the three-scan rule:

"Lung cancer survival depends largely on the stage of the cancer when it is diagnosed. New screening coverage is expected to result in diagnosing more early stage lung cancer, which is more likely to be treated successfully and with surgery. While CMS had agreed to more screening scans, in 2013, it said that it would fund only three posttherapy follow-up FDG PET/CT scans per patient and per tumor type, including lung cancer. Any additional follow-up PET/CT scans will be funded only at the discretion of a local Medicare administrator, CMS has said. "In other words, if you want to do more than three, you will have to justify it," says Rathan Subramaniam, MD, PhD, MPH, an associate professor of radiology and radiological science, oncology, head, and neck surgery, and health policy and management at Johns Hopkins Medicine Division of Nuclear Medicine in Baltimore."

radiologytoday.net/archive/...

I don't know if all of our scans get justified or whether this whole thing is obsolete at this point; many of the CMS documents don't have dates or have not been updated in years so it's really hard to tell. Apparently if many people in this forum were denied more than three PET scans we'd be hearing about it.

tango65 profile image
tango65 in reply to TeleGuy

The info I have is that they will pay if the patient had prostatectomy radiation or chemo and the pet ct is needed for restaging. No mention about a total number per year or in the life of the patient.

I paid $3,500.00 at UCLA in March by way of credit card. They subsequently deleted the charge. Thankfully FDA approved PMSA test in December.

Tough deal that our Gubmint is so slow. I suspect lobbying, recouping of investment in equipment, etc…. Reason is so slow in making scary life saving tech available.

Just saying.

Looks like only at UCSF and UCLA, still waiting for Medicare approval for other locations.

Ed

Concerned-wife profile image
Concerned-wife in reply to EdBar

That is how I read it, too. I asked the PCF via Facebook to please monitor and update us. They employ a government rep and this request seemed like something under their purview.

Tim said he’d checked into it.

Medicare pays for the Ga 68 PSMA PET/CT at UCLA and UCSF and they pay for Pylarify in other institutions. The document shows the specific codes that have to be used to bill for Pylarify.

ImaSurvivor1 profile image
ImaSurvivor1 in reply to EdBar

Can anyone tell me pros and cons of getting the Ga68 PSMA scan at UCLA vs. UCSF? Thanks.

tango65 profile image
tango65 in reply to ImaSurvivor1

Apparently both are covered by Medicare now. The main pro is that SF is a beautiful city. I do not think it makes any major difference having the scan in one place or the other. I had PSMA PET/CTs in both and I do not believe there any significant difference.

ImaSurvivor1 profile image
ImaSurvivor1 in reply to tango65

Tango65. Thanks for the info. Did you have a relationship (doctor) in either of those hospitals before you got your scans? If I get the scan at one or the other, I'm wondering if their radiologists will evaluate the scans and if a doctor there will go over it with me, or if I'm going to need to be referred to a doctor there before I get the scan. Thanks.

tango65 profile image
tango65 in reply to ImaSurvivor1

Your doctor can order the study at UCLA or UCSF. Their radiologists and nuclear medicine radiologists will read the CT and the PET and make a final report of the PET/CT.

You should order a CD or DVD of the study and bring it with you.

Your doctor will get the report, and you can provide your doctor with the CD/DVD and they introduce the images in their electronic system.

Your doctor can read the study or request that the radiologist/nuclear medicine people at his/her institution review the scan and make a report.

I was in this situation when a supposed rib met was diagnosed at UCLA, the doctors at my institution were not sure so they ordered a MRI and not metastasis was detected.

Great news. I am especially interested in what you said re Medicare advantage plan coverage as my retiree company is switching to Unitedhealthcare Medicare advantage and am very concerned about coverage for many items. As a newer item, PSMA is a good example. Having trouble going through all the medical items to what won’t be covered.

Where did you get the info re Medicare advantage coverage for PSMA?

tango65 profile image
tango65 in reply to podsart

It is approved for payment by Medicare so they should pay for it. Medicare advantage manages your Medicare insurance they should not refuse to pay for procedures approved by Medicare. Sometimes Medicare Advantage plans refuses to pay for consultation and studies done out of the Medicare advantage network

You need to talk with Unitedhealthcare and find out if they will pay for it. Each Medicare Advantage plan is different. If an Institution in the network of your Medicare Advantage plan performs PSMA studies, most probable the plan will have to pay for it.

When one gets into a Medicare advantage plan, one surrenders the Medicare insurance to the insurance company and they manage the Medicare insurance. It cost less, one has many benefits but one can not use one's Medicare to go and see any doctor or have procedures in any hospital that accepts Medicare unless the insurance company managing the Advantage plan authorize the consultation or the procedure outside the network.

Be very careful with advantage plan. Most of my Pca patients that run into financial issues are in advantage plans and stuck cant change during open enrollment like u can with supplements. They ate notorious for denying treatments also.

tango65 profile image
tango65 in reply to Drgucancer

If the scans are done outside the network they can not approve the payment. Advantage plans own the patient's Medicare so they can do whatever they want.

podsart profile image
podsart in reply to tango65

Thanks

podsart profile image
podsart in reply to Drgucancer

Thanks

Do you have the time to explain the difference in the scans? I never completely understand! Want to make sure husband has the latest available .How do we find locations for it? We are in Nashville. Thanks in Advance. 5th Xofigo treatment so assuming after 6th new scans. Then discuss what should be next.

tango65 profile image
tango65 in reply to Yorkielover2

Both scans are the most sensitive scans to detect prostate cancer lesions greater than 4 mm. A bone scan and a CT scan can be normal in a patient and a PSMA scan may show multiple lesions. The use of these scans usually changes the treatment plan in around 40 to 60 % of the patients, when the plans were done using CT and Bone scan.

The scans use radioactive ligands which find a protein called PSMA which is present in the surface of the PC cells. PSMA is also present in the salivary an, lacrimal glands, kidney, liver, small gut .

Ga 68 PSMA and 18F DCFPyl (Pylarify) have different ligands. It seems that Pylarify has a better detection rate of lesions in patients with a PSA lower than 0.5-1. At higher PSA values I believe there is not much difference.

Yorkielover2 profile image
Yorkielover2 in reply to tango65

Thank you

Thanks for the update, whew!

Yay!! I turn 65 next May and have another Axumin scan tomorrow. PSA rising (doubled in 2 months to 5.5), despite the 6 Taxotere rechallenge in Spring 2021. Had 15 Taxotere sessions in 2015 and the PSA went from 840.2 to 0.7 that year.So, the PSMA scan may be able to detect PCa that the Axumin may miss.

Mahalo for the info

Fight on y'all

Randy

Is there anyplace offering this on the east coast? In NYC perhaps?

tango65 profile image
tango65 in reply to Don_1213

I assume there are. Any institution with a PET/CT scanner can do the test if they can get the Pylarify. The Sloan Kettering for sure do the Pylarify, since they were part of the clinical studies.

Does the government pay for the donuts?

Good Luck, Good Health and Good Humor.

j-o-h-n Monday 10/11/2021 10:52 PM DST

tango65 profile image
tango65 in reply to j-o-h-n

Only for the hole.

LOL.... As you go through life.... Let this be your goal, keep your eye on the donut and not on the hole.....

Good Luck, Good Health and Good Humor.

j-o-h-n Wednesday 10/13/2021 9:07 AM DST

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