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

[ac61418]

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?

[Tall_Allen]

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 in reply to Tall_Allen]

Thanks

[tango65]

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:

pylarify.com/coding-and-bil...

Look at page 69 of this Medicare document

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

[ac61418 in reply to tango65]

Thanks for the info! much appreciated

[tango65]

Your are welcome. Best of luck.

[Concerned-wife]

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. mayoclinic.org/patient-visi...

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

[Hidden]

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!

GD

[slpdvmmd]

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]

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]

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 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.

[Hidden in reply to V10fanatic]

Did you get a response. tracer is not an injectable medication, so no part B

[V10fanatic in reply to Hidden]

I had to pay the 20%. My appeal was not approved. At least I know what to expect next time.

[Hidden]

The key word is "drugs" "injectable drugs"

Tracer is not a drug. Contact CMS, and plead your case.

I dont pay for PSMA tracer, nor CT tracer.

I do pay 20% of Lupron, and I make sure it's 20% of the preferred discounted price. The price paid by Medicare, not the price billed.

[Fightinghard]

I had similar bill about 3 years ago when I was billed $23k for a scan. When I challenged the provider they said since I had not signed a doc prior to treatment that stated medicare did not cover that i was not liable

check into the “no surprise” billing rule thru medicare providers. If they told you the treatment was covered, then they might have to write-off their bill.

medicarerights.org/medicare...