My PSA has gone up from .1 t0 3.5 in the last 6 months. Aetna told me to go pound sand and denied my request for the PSMA scan. Does anyone know how much it would be out of pocket to have this
scan done. I am tired of putting my life in the hands of impersonal unthinking give a shit bureaucrats. If you think this is bad wait for socialized medicine....or all we already there?
You should find out what the negotiated rate would be for that had it been approved. Totally different from the billed amount. My PSMA was billed at $19,900 - I still haven't seen the EOB.
$19,000, talk about a scam, holy moly, all hope is lost. omg.
The US medical system! In Australia until 1 July 2022 the PET scan was covered, but the GA68 component was a USD400 payment, now its free under our "socialist" universal medical cover. SOC here is a scan every 12 months.
Only if it is indicated, and your MO decide about it.
I was told that the 68GA PSMA PET scan is not indicated for me.
I didn't have a single scan in a last almost 4 years. My last bone scan was a nuclear medicine bone scan after my early chemotherapy.
I believe if your PSA is low they will only order a CT scan and the nuclear medicine bone scan.
They are just checking with that usualy yearly scans that you didn't develope a low PSA producing cancer. (endocrine? Or something similar?)
Here in Australia they will not order for everyone the PSMA PET scan (medicare will pay but the oncologist will not order it.)
I know, I asked for the PSMA PET scan multiple times but my MO didn't recommend one, only a bone scan and the CT scan.
In Canada it is the same like here in Australia.
If you receive your injections in a public system hospital it should be free, but they ask you to bring your Firmagon monthly injections with you and they are not happy that you are coming to them for injections.
They want you to go privately and get the injections there.
Therefore, like i learned in Switzerland. "Recht haben, und Recht erhalten ist zweierlei."
I just hope that they will not stop prescribing my Firmagon injections.
So it is like that here. Maybe in USA if you pay you can get it. Here not. I understand that. We have to many sick people.
It looks good, it is free, but the reality is you are not getting the scan.
is that like that appealing to the IRS? Evicore is the outfit that does the Aetna dirty work.
well the spike in PSA means it is on the move. The PSMA scan is the only way to have eyes on it. Isn't this correct?
I just had both and nothing changed. The rising PSA suggested a PSMA scan would show what is up. This was suggested by Doctor Havord at Utah Cancer Specialists Oscar Goodman at Comprehensive Cancer Centers and the technician who administered the bone scan at SDMI
.3 ? That is negligible. Mine went from .1 to 3.5 in less than a year.
the appeal should be done by doctor not a patient. true? What is Plarify?
Pylarify is a PSMA PET/CT scan that uses the ligand 18F DCFPyl instead of the Ga 68 PSMA 11.
either the doctor or patient can appeal. More effective if the doctor does. They know what info to include.
It is the patient's insurer, so patient appeals, but a good Doc will provide a wriiten reason and logic for the requested scan......plus the Doc may know of other similar situations in which the scan has been approved by other insurers or Medicare for seniors. Most insurers would cover stuff that is covered by Medicare in USA.
He needs a PSMA scan to see if the metastases are PSMA positive and with enough SUVs to get treatment with Lu 177 PSMA. They do not Lu 177 PSMA based in a bone scan or a CT scan.
that is perfect. Where do I send a check?
The doctor's office should appeal and get it approved.
my doc think Xofigo would be a better choice for me. Will talk with him Tuesday
How many bone mets do you have? Are your bone mets painful?
If your bone mets are not painful and you don't have many of them, would you at least consider SBRT of your mets? I am not a doctor but why would you use Xofigo infusions without a good reason? Could you explain better your doctor thinking about Xofigo?
Did you have chemotherapy? Maybe that is what you need? A system therapy for PSMA positive and also for PSMA negative cancer not yet visible on any scan?
It is no point to tell you anything at this stage untill we know more about your treatment preference.
Has the doc talked to them? Blue Cross initially rejected my PSMA scan. My MO had a consultation with them and worked out that they would approve it after I got additional CT and bone scans, which I did and they approved it. At the time my PSA was 0.9. The doc couldn’t quite figure out why they wanted the additional scans. I had already had them twice before and the new ones didn’t show anything earth shattering. But they were going to pay for them so we went along.
If that doesn’t work out appeal it. Don’t know what the process is in your state but in Vermont there can be three rounds of appeals. They can be expedited if needed. The first two rounds are internal with the insurance company. The doc handles those. If they don’t work there’s an external appeal to an outside independent arbitrator. I’ve had to go that far twice. Both times they ultimately approved the procedures.
Good luck!
that is good info, I am talking to my doctor next week. Thank you
PSMA PET scans are approved for only two indications:
(1) For high risk, localized patients before treatment
(2) After first-line treatment, if PSA has risen above the level of biochemical recurrence (0.2 after RP or nadir+2 after prostate RT)
If either sounds like you, you can appeal. If not - why are you asking for the test?
I had chemo after brachey therapy and radiation in 2018. My PSA has risen from .1 to 3.5 in the last six months while on Erleada 260 mg and Orgovyx the last 12 months. does that answer the question Tall Allen ? I am 6.4' but nobody calls me tall Jim
You don't fall into either of those 2 categories. Your post doesn't really answer the question. Erleada has stopped working, and I would think you'd want confirmation on a bone scan/CT (if you had high risk PCa when you were first diagnosed in 2018, you should have had your baseline bone scan/CT back then). What decision would a PSMA PET/CT help you make?
I have multiple bone metastasis in my spine.
One of them is a bone metastasis in my neck just under my skull and that is my major concern now.
I am currently only on Firmagon, ADT injections.
I had an early docytaxel chemotherapy 6 cycles four years ago starting with the chemo 2 months after starting Degarelix ADT injections. (Therefore the name early chemotherapy.)
My PSA dropped from 100 down to the nadir of 0.12.
My PSA started slowly to rise in the last year and now accelerating. In the last month my PSA jumped from 0.95 to 1.25.
Now my PSA is 1.25 therefore I would prefer a 68 GA-PSMA PET scan in order to see if I developed any activ metastasis in my brain? Plus to see if I have a spinal cord compression?
If yes, than it is better to SBRT my brain metastasis now (early) than to wait too long? (If it is possible to use SBRT. )
I have to talk to a RO about this possible approach and I already made an appointment for that purpose. (Maybe i will also ask for a second opinion from the DFCI radiation oncologist?)
I could also SBRT any on the PSMA PET scan visible active metastasis (if any) and if the location of the mets make it possible. (Without damaging vital organs. Etc.)
The SBRT of the active mets could bring positive immunological changes against the cancer? (Do you have an opinion abot this approach to help with my cancer?)
Or maybe it is better just to simply escalate my treatment to the next level and that could be Enzalutamide plus Cabazitaxel (rather than radiation alone. Radiation could be even postponed if the therapy will be successful.)
I could ask for a biopsy of one of my active metastasis (if the PSMA PET scan will see any) in order to see if the cancer developed some actionable mutations which could be addressed either with Olaparib or Keytruda etc.? (Before the radiation of the active mets?)
What do you think? Could they approve a PSMA PET scan for me?
Please give me your honest opinion (I can see that you are knowledgeable) and which approach would you take if you were in my shoes?
István
Your PSA is rising rapidly. Consider cabasitaxel chemotherapy.
Chemotherapy works best when the cancer cells are rapidly dividing and that may be your case.
Do you have also radiological progression of the cancer?
I wouldn't use Xofigo just now as you dont have bone pain yet? And even than you could just use SBRT to radiate your painful bone mets.
I would save Lutetium PSMA therapy for later if your cancer is still low volume.
It is not recommended to use Lutetium PSMA treatment for low volume cancer as this therapy could have higher toxicity when used for low volume cancer.
Here is the explanation:
ncbi.nlm.nih.gov/pmc/articl...
The other reason not to use Lutetium PSMA therapy now is that the maximum number of Lutetium infusions is limited to 6 in your lifetime.
You should find a capable oncologist to advise you. This forum is for ideas only and not to make a final decision.
I paid $6500 for PSMA at SMIL clinic in Chandler this past January. 2022. When SBRT treatment did not show results, I just wanted to know the comparison from PSMA done at UCLA in June 2021.
Could you please fill out your profile information if you want us to reply properly?
I don't think that the cyber knife wasn't accurate. Maybe it really needs some time to work?
Maybe you have other mets growing?
Try systemic therapies. Only the PSMA positive cancer show up on the PSMA PET scan. Can you list all your treatments until now. Can you ask for a biopsy?
You should explain better your clinical situation if you hope for any answer to help you.
I'm guessing I have great insurance. Couple LU-177 treatments so far, abiraterone, etc, etc, all the accompanying stuff, almost zero out of pocket. You all know way more than I, I'm not good at this stuff, can barely tie my shoes... 😁
I will hold everyone in my thoughts. I hope they find a cure for us all. THEN, they figure out a way to make it affordable for us all!
that was my question
I would like to change MO. My MO is very busy and we never talked about my treatment options.
I found a lady MO and I will try to transfer to her. If it is not possible than maybe I have to move to Melbourne to PeterMacCC. Here wher I am I had a neurologist but he is a stroke specialist and the director of the stroke unit here in Sydney St Vincent's public Hospital.
I didn't see him for more than 3 years by now. I don't know if he is qualified for brain cancer.
I will try to get a team. I always thought that the advantage of being a patient in the public Hospital is that you have a team looking after you. Maybe only on paper?
Thanks for your response.
You are correct I have to start the process of seeing different specialists.
What you said makes great sense to me.
Now when my PSA started to rise i have to be more active. I thought that my MO should do all of this recommendations and that it is enough to be a patient of the public Hospital.
My ex wife though the same for her father beliving that it is enough to put him into hospice care.
Unfortunately we should be more proactive instead of waiting for the doctors to provide recommendations. You have to fight for your life.
well said. God bless.
your Doctor needs to appeal/provide more info and reasoning for the request, and keep advocating for the scan. I had similar situation; my medical team had to “appeal” and speak with insurance review 3 times before I got a “one time conditional approval”that Anthem said was only an exception to the denial. The Pylarify scan was very useful for me, even after 2 prior Ga68 PSMA scans I got on a trial at UCLA for $2500 USD each over the past several years. I think insurers are very reluctant to start approving these too early due to cost, but my opinion is they should and will soon replace CT/Bone scans as SOC.
There is always an appeals process. Your physician should assist you with a letter stating why the PSMA is needed. Your letter and phonecalls should be documented and copies sent to the state insurance commissioner office. Every state has an office that overlooks what insurers do.
In the past when I reviewed appeals in my specialty area of medicine both letters from the patient and physician were included in the data sent to me. I would add the review process is far from fair and full of many middlemen who often will "shop" your appeal trying to find a reviewer who gives a negative response. My experience during my course of care when totally blocked is to weigh the cost of paying out of pocket here vs going overseas for a "vacation". When I have paid out of pocket here and been correct as I did with a PSMA PET I appealed and was later reimbursed at least a portion of my expenses. Always remember the insurers pick and choose how they interpret the "science" so it is their favor.
thanks for that. Here is where I am with it. I talk to my doctor today, if he thinks I can benefit from the PSMA scan I will pay out of pocket, I ave an HSA account, the cash value is $2000 at SDMI. When they bill insurance 5 x the amount you can conclude socialism and socialized medicine is a total scam.
I think insurance in the US is a criminal enterprise. I state this as a patient and as a physician, both sides is a chronic fight. I have not faith either political party will may any substantial change to this criminal enterprise.
you are right about that. Doctor Havard did what Oscar Goodman could not. He had insurance bow down and pay for the PSMA scan. Incidentally it is a CT Scan Pet scan machine. The PSM is a fluid that cost 4k they injected me with. Waiting for results now, God bless all.
For what it's worth- after 9 years my PSA became measurable at .06. The following 12 months it rose steadily to .32. I don't know how my MO got UnitedHealthcare to approve the Plyrafy scan, but I am pretty sure they did (I am also covered 2ndarily by the World Trade Center Health Program, so it's possible they covered it, instead, but I believe it was United). Glad they did, as my MO (along with the radiologist) determined my rising PSA was likely do to ONLY my largest tumor, located in my hip. It was radiated and my PSA dropped back down to immensurable. Hopefully, it will remain that way for a while. Did you ask your MO to appeal the decision, which you are entitled to do?
All one has to do is ask the cash price versus the price if they run it through insurance for a medical procedure. Does this have to be spelled out.? As for the lawyer non- sequitur, what do you call a lawyer run over by a truck? A good start.
I was able to get the PSMA scan at Utah Cancer Center. Waiting for results now. Great place. Never asked for a credit card or anything. Just walked in and said bye when I was done and walked out.
My father was failing at 86 and they ran tests non stop. Then billed Medicare. Nobody will ever convince me that a third party involvement does not encourage what is going on in this country. It is criminal.
there is a wrong and right. As far as the narrow definition you use of criminal, this is an evasion. Thinking is man’s only basic virtue, from which all the others proceed. And his basic vice, the source of all his evils, is that nameless act ,but never admit: the refusal to think—not blindness, but the refusal to see; not ignorance, but the refusal to know. It is the act of unfocusing your mind and inducing an inner fog to escape the responsibility of judgment—on the unstated premise that a thing will not exist if only you refuse to identify it, that A will not be A so long as you do not pronounce the verdict “It is.” Non-thinking is an act of annihilation, a wish to negate existence, an attempt to wipe out reality. But existence exists; reality is not to be wiped out, it will merely wipe out the wiper.
Another non sequitur. I am explaining that the third party system for doctoring sets the stage for grifting, fraud, and excessive billing. The government has a 100 page list of what defines prostate cancer and what constitutes disability. This is nuts. Anyone who thinks this is a good thing must be a hard core liberal who defend the indefensible. I am very happy and enjoy every day. I did not start this exchange but enjoy it immensely.
Absolutely think the government is a criminal enterprise! The first thing you have to realize is all CMS does is collect money and give it to Medicare and Medicaid private contractors, CMS is not a prototype of single care government run system. You also need to drastically trim the administrative burden and number of parasitic administrators/educators/chiefs and other non-patient contact individuals feeding off the system. The highest paid people in healthcare are not the people providing healthcare. Also you do not need to give CEO's bonuses for limiting care and you need to do away with the non-prophet scam. You also somehow need to make healthcare a caring profession again by reinstating the Dr/Patient relationship, something that has been purposefully destroyed because it takes away power and the ability to make decisions and puts it in the hands of committees. I could go on for hours but a good starting point would be putting caring people at the top who are still required to actually see and care for patients and who then help set the tone for care.
Minimum PSA for GA-68 PSMA Scan
PET PSMA scan and low PSA and Lurpon
Delaying firmagon a few days for psma scan
PSMA PET-CT Ga68 Scan results
Cost of PSMA PET scan?
