PSMA PET coverage is FDA approved for 3 situations:
1. High risk, localized
2. Recurrent after radical treatment
3. Before Pluvicto
You may be interested in the frustration expressed in writing by these doctors: "Now, we must write again about major U.S. insurance companies, including Anthem Blue Cross, United Healthcare, Cigna, Blue Shield, and Aetna, and their repeated and inconsistent non-coverage decisions arbitrarily denying clinically indicated prostate-specific membrane antigen (PSMA) PET/CT imaging studies in around 10% to more than 60% of their patients "
It would also be good if those decisions were not taken on behalf of the insurers by MDs unknown with cancer treatment or, at the very best, only skirted the topic in medical school. In my case, SBRT was rejected initially by a pediatrician working for Anthem BC. She knew better than my radiation oncologist, an expert in this field, what would be the best treatment for me.
We just went through this. Insurance initially denied PSMA PET. Our doctor appealed it in a peer to peer review and got it approved. But they certainly have more important things to do than have to schedule these appointments and deal with insurance appeals. Oddly the insurance doc he spoke to was a pediatrician but she recognized the need. Now we're all wondering what kind of hurdles await us with Pluvicto treatments. Thank you TA for this post. It's hard enough fighting cancer but the stress of getting insurance approval makes it even harder.
Question - for those guys that are getting denied - What codes are the insurance comanies using on the EOB's for denial? What is the reason for denial? Thanks
“there are not enough medical studies showing that this test is better or safer than other tests that can be done for your problem. Other tests (which are typically considered standard of care) can be covered. These include chest CT and abdomen/pelvis CT.”
Thanks TA - I've been hounding these companies for 30 + years - I'm an insurance broker and I run across this all the time. How many medical studies do they need? Clearly the Test has been provided worldwide for years.
Something to consider - and as boring as they are, read your Insurance summary plan description. Also, get the CPT codes in advance and have them pre-approved. Appeal denials before you get care, not after. There are basic tenets under the law with regard to insurance denials and insurance contracts in general, primarily, unless a procedure is specifically not covered under a policy, it must be covered. The example sited in the article that TA posted is a perfect example of a bogus denial and a lawsuit waiting to happen. Once the peer reviews are completed, the FDA and AMA will or will not approve the procedure as an accepted standard of care. Plainly, if the treatment is approved by the AMA and is not specifically excluded from coverage in the summary plan description, it has to be paid. I have never seen a summary plan description that stated care must be covered by Medicare.
Unfortunately, insurance companies arbitrarily decide against paying for procedures that are the SOC and have been approved by the FDA. That is the point. Probably, it will be overturned with appeals and peer-to-peer review.
Thanks Tall Allen. Wonderful advice. I have appealed many things over the six years we have fought this beast. I’ve only ever lost once. And it had nothing to do with his cancer. It was actually a prescription for eardrops. The doctor just shrugged and gave him two drops that he said essentially did the same thing and actually cost more than the drug they refused to pay for. Go figure.Insurance companies expect most people will not appeal. I have found that if you appeal you usually win. But I have had to escalate a couple. The secret is to keep fighting them. Yes, I know it’s hard when you’re also fighting cancer. And it’s sad that our country‘s health system is set up this way. But if you refuse to go away they usually give in.
Excellent info! I tried several times to get this scan approved for my G9 PCa was informed it was not approved or that it would not be approved. Honestly, I don't even think the RO's tried, going by their old data of coverage I am thinking. At this point my PSA is down to .11 and to low per UCLA. Good news is I had HDR Brachy therapy last week at UCLA and will start IMRT in a few weeks. Hoping to get this thing on the run.
Thank you for including the references. Very interesting reading. My husband is basically the example that was given in the article. Very high PSA (88) Urologist wants to know if it has met and recognizes that the PSMA - PET is a more sensitive test so ordered it but insurance denied stating “PET scan is a test that takes pictures of the inside of body. It would medically unnecessary for initial treatment planning for this type of cancer. Therefore, we cannot approve it.” First of all - what do they mean this type of cancer ? PSMA PET is specifically for this type of cancer 2. CT has already been done. 3. He is very high risk candidate. Something is off here - Do you think it was coded incorrectly? Should that should be brought up in our appeal??
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Medicare Coverage for PSMA Scan
Medicare will pay for PSMA PET/CT Studies.
Medicare did not pay for the Pylarify used in PSMA PET/CT Scan
How is PSMA PET scan being used in your experience?
PSMA PET required for LU PSMA therapy?
