Medicare did not pay for the Pylarify... - Advanced Prostate...

Advanced Prostate Cancer

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Medicare did not pay for the Pylarify used in PSMA PET/CT Scan

ac61418 profile image
11 Replies

Received the EOB for my Pylarify PSMA scan. The facility billed about $10,000+ , half for the PET/CT, and half for the Pylarify. Medicare allowed $1800+ for the PET/CT but zero for the Pylarify. I was previously told that Medicare covered the scan and tracer. Has Medicare changed their policy recently? I was diagnosed and treated for Gleason 9 disease and rising PSA post treatment, suspicious for recurrence, MO ordered scan to confirm. Will I be on the hook for the $5000+ cost for the Pylarify?

11 Replies
Tall_Allen profile image

If you had primary radiation therapy, and your PSA rose to 2.0 or more after, they must pay for it. On your medicare bill, there is a code for the reason they refused it. Call the number on the back to talk to CMS for an explanation. The hospital may have entered the wrong code. Never pay what the hospital charges - it's a ridiculous amount they don't really think they will get.

ac61418 profile image
ac61418 in reply to Tall_Allen


tango65 profile image

Call your doctor's office and explain what is happening and they should proceed to get Medicare to pay for the study. It is a procedure covered by Medicare. If they refuse, then you will have to deal with Medicare directly.

They are some of the codes they need to use:

Look at page 69 of this Medicare document

ac61418 profile image
ac61418 in reply to tango65

Thanks for the info! much appreciated

tango65 profile image

Your are welcome. Best of luck.

Concerned-wife profile image

Sounds like a provider billing mistake.

If denied for lack of medical necessity, hopefully you hadn’t signed an ABN. Here is Mayo explaining what these are.

Always appeal (and ask provider to) if the provider doesn’t get this corrected

gourd_dancer profile image

A general statement, do not delay and follow the time allotted for billing questions and appeals. My case in point, lab work that miscoded at the CME on a lab charge that had previously been paid fir in excess of 30 times and since; all with the same provider, was finally denied, even after their resolution pro agreed; yet I took too long to appeal..... damn bureaucrats!


slpdvmmd profile image

Definitely talk to ordering physician and have them resubmit. Just think this is a study that cost's less than $100 in some areas of the world!!

maggiedrum profile image

I would agree about the doctor followup and also the appeal. You should ask the doctor to specifically help with the appeal. Follow the appeal process to the letter. AND recheck your Medicare and insurance processor to see if it is excluded or you have a co-pay or high deductible on your specific plan. If in Medicare Advantage then the private insurance provider sets additional rules for coverage. If on Medicare Supplement then the specific Plan you picked will have specific deductibles for different procedures. Good luck.

V10fanatic profile image

My Advantage plan is still "processing" my claim after nearly 7 weeks. I guess I need to contact them to see what's actually going on.

V10fanatic profile image
V10fanatic in reply to V10fanatic

United Healthcare finally contacted me back. Seems they are classifying the tracer as a "Part B" item and are charging me a 20% co-pay. Seems unfair, but I'll need to appeal to get something in writing from them. I couldn't find anything in my policy documents concerning the Part B issue.

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