Advanced Prostate Cancer

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GMan-62 profile image
22 Replies

I have been on Casodex and Eligard since June 2022. My PSA was still high after RALP so I had a GA-68 PSMA PET Scan done which revealed one 11mm tumor in the Left pelvic Lymph Nodes and one 7mm Tumor in the Right pelvic Lymph Nodes. Those were the only 2 hot spots in my body. My Dr. scheduled me for IMRT (38 rounds total) which started August 16th, and he wanted to find the baseline for my bone density before the IMRT started and since I'm on ADT so he ordered a DEXA scan.

When I was checked in to get the DEXA Scan, the Office where I had the scan done had a hard time finding the proper ICD code for the scan. They finally found something they said would work and sent me to have the scan done. They also had me sign a form saying Medicare may not pay for the test and I may be responsible for it. I'm on traditional Medicare and Tricare for life. Medicare denied the claim for the DEXA scan which was $500 and for the Dr. visit for the DEXA scan which was $135. Since Medicare denied the claim, Tricare has also denied the claim. I have been searching the internet for the proper ICD codes to use for a DEXA scan for males with prostate cancer but can't find any.

Has anybody else had a DEXA scan that was paid for by Medicare?

22 Replies
GoBucks profile image

Weird. First of all, a dexascan should cost 1/2 that much. Secondly I have now had 2 covered my Medicare. My dexascan was done at a hospital. Do you use Dr Vinnie Boombatz?

GMan-62 profile image
GMan-62 in reply to GoBucks

Thanks for the Information. I live in Pensacola, Florida and had the scan done at a Baptist Hospital facility. Do you by chance know what ICD code was used? I'm probably going to have to call billing at the hospital and find out what happened and if they will resubmit. If I have the proper ICD code I can tell them what to use. I run into a lot of providers that submit the wrong codes and I have to find them. I'm seeing Dr. Timothy Brand Urology Oncology and Dr. James Adams Radiation Oncology. Both at Baptist Hospital. Baptist Hospital has a partnership with the Mayo Clinic.

Gabby643 profile image
Gabby643 in reply to GoBucks

Rodney's best!

tango65 profile image

Yes, for sure you can get one every 2 years and more frequently if medically justfied.

GMan-62 profile image
GMan-62 in reply to tango65

Thanks for the response. That's what I thought from everything I've read, but for some reason it was denied. Do you by chance have the ICD code they billed with. Thanks.

tango65 profile image
tango65 in reply to GMan-62

tango65 profile image

They are covered, I have had several along the years, every 2 years and they were always covered.

tango65 profile image

It is confusing . The full version of the regulations says:

80.5.6 - Beneficiaries Who May be Covered

(Rev. 70, Issued: 05-11-07, Effective: 01-01-07, Implementation 07-02-07

"To be covered, a beneficiary must meet at least one of the five conditions listed below:

1. A woman who has been determined by the physician or qualified

practitioner treating her to be estrogen-deficient and at clinical risk for osteoporosis

based on her medical history and other findings.

2. An individual with vertebral abnormalities as demonstrated by an x-ray to be

indicative of osteoporosis, osteopenia, or vertebral fracture.

3. An individual receiving (or expecting to receive) glucocorticoid (steroid) therapy

equivalent to an average of 5.0 mg of prednisone, or greater, per day, for more than 3


4. An individual with primary hyperparathyroidism.

5. An individual being monitored to assess the response to or efficacy of an FDA approved osteoporosis drug therapy."

I believe we are covered by numerals 2 and 5 and possible 3 for those treated with Zytiga plus prednisone.

If one is being treated with Denosumab or zoledronic acid or similar, the DEXA is ordered for monitoring ongoing osteoporosis drug therapy.

I believe if a patient is on ADT and is not being treated with these drugs, the doctor may request the study to determine if these drugs are needed (baseline). Osteoporosis requires treatment and the diagnosis of osteoporosis is a T value less than -2.5 in a DEXA scan.

dhccpa profile image
dhccpa in reply to tango65

Thanks for that info. I have my first one since I've been on Medicare coming up next month. I had a previous one two years ago on private insurance.

maley2711 profile image

From for bone mass measurement..........

covers this test once every 24 months (or more often if medically necessary) if you meet one of more of these conditions:

You’re a woman whose doctor determines you’re estrogen-deficient and at risk for osteoporosis, based on your medical history and other findings.

Your X-rays show possible osteoporosis, osteopenia, or vertebral fractures.

You’re taking prednisone or steroid-type drugs or are planning to begin this treatment.

You’ve been diagnosed with primary hyperparathyroidism.

You’re being monitored to see if your osteoporosis drug therapy is working.

It's not mentioned there, but I've read would be covered for men at age 70 or older?

BTW, are you age 60? Jus wondered, since Medicare would not be your coverage at that age?

GMan-62 profile image
GMan-62 in reply to maley2711

I’m on Social Security Disability. Once you have been receiving it for 2 years you are eligible for Medicare. I’m retired military and wanted to keep my Tricare insurance but once I became eligible for Medicare I had to take it or Tricare would cancel my Tricare insurance. Now Tricare acts as a gap insurance and covers what Medicare doesn’t. That is unless Medicare doesn’t cover it. Then they won’t.

Grandpa4 profile image

10 years ago we stopped doing Dexascans because Medicare only reimbursed us $75 and we could not afford to do them. Can’t imagine it is $500 now. Guess it will end up being much cheaper. I also had a dexascan on Medicare without a problem. . Your oncologist should know the code. They do this all the time. I would explain the problem to them and ask them to resubmit with the right code.

kreg001 profile image

77080-PN for the measurement. 77080-26 for the radiologist.

Maybe age related. I was 74 at the time.

anonymoose2 profile image

Did for me 3 times.

wilcoxsaw profile image

Mine is covered every 2 years by medicare

TEBozo profile image

Do you have a Medicare supplement policy?

GMan-62 profile image
GMan-62 in reply to TEBozo

Yes and no. I’m retired military so when I became eligible for Medicare my military health insurance turned into something called Tricare for Life. It pays all my Medicare deductible and the 20 percent not covered by Medicare.

So far all of my treatments for PC have been covered by Medicare and Tricare for Life. I’ve had no out of pocket expenses. This DEXA scan is the firs time something has been declined. Hopefully the provider will be able to find the right codes to resubmit and get Medicare to cover it.

spencoid2 profile image

i had a dexa scan that was covered by medicarethere may be standards for qualification for payment but everything i can find online says that medicare part b pays for it

GMan-62 profile image

Thanks for all your responses. I’ll have to work with the provider to get them to resubmit and hopefully this will be resolved.

Teacherdude72 profile image

Had several with Medicare..they were free.

Mine has for the past 7 yrs . They are given bi-annually ..

The dexa must be the cheapest of any scan that we get?

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