GA68 PSMA Pet/CT and private insurance push back

[TJS-1]

Just an FYI post. Had 2 prior PSMA Pet/CTs under the UCLA “trial” program- July 2019 and Dec 2021. Both useful to inform treatment plans; both before FDA approval, and were paid out of pocket at a discount ($2800 USD or so).

Latest scan was inconclusive (PSA too low), waited for significant PSA rise to re-scan. Private insurance is Anthem Blue X; has always been great with coverage and pre-auths. Assumed that would continue since FDA approved the scan technology, but my private insurance has now denied 2 prior requests for pre-auth stating a bunch of reasons including “not medically necessary.” Finally capitulated after a 3rd go- around with me, RO and MO; scan scheduled for 8-18.

Appears private insurers intend to automatically deny PSMA pet/ct scans unless you really fight for them, despite FDA approval, and even if you’re in the sweet spot of criterion for which FDA approved. VA and Medicare may be more liberal in authorizations - anyone have a better experience with private insurers outside of UCLA and UCSF facilities?

[AlanMeyer]

I don't know enough about what goes on behind the scenes at insurance companies. My impression is that some of them are worse than others. In John Grisham's novel Rainmaker the hero of the story runs across an insurance company that has resolved not to pay ANY claims larger than some small amount unless they are forced to.

My own insurance is a Medicare Advantage plan with Kaiser Permanente, an HMO (Health Maintenance Organization). I've sometimes asked them for things that they won't pay for but they've always given me reasons that made sense. On the other hand they've sometimes paid for more expensive things with no push back at all.