My dad had a PSMA PET Scan scheduled for next Monday via UC Health in Denver and was just notified that insurance / Medicare denied the scans and they have scheduled him for a bone scan / CT scan in its place.
Does anyone have any experience with that situation in getting a scan approved? We could be willing to pay out of pocket if this can’t be approved as my understanding is this scan is very important.
His biopsy was Gleason 9, positive in 8/12 cores so very agggressive. Thank you very much.
I had similar situation. G9, they required bone scan first, then MRI. Once that showed positive, they approved the PSMA. I was able to get it all done within 2 months.
Medicare approves it for high-risk patients. Is this an Advantage plan that denied it? Appeal!
Medicare + Plan F via UnitedHealthcare
My understanding of UnitedHeathcare plan F is that it covers the 20% of part B of any claim honored by medicare. So, the problem may be with medicare.
It is definitely covered under a supplemental plan. Call CMS for an explanation
(800) 633-4227
- maybe the hospital entered the wrong billing code. I've found that they are very helpful once you get through on the phone.
My PSMA scan was initially declined but insurance would approve bone and CT scans - again. I’d already had two of each. After that the PSMA scan was approved. Added about a month to the process. This was all worked between my MO and the insurance company.
Great plan.
Do no know if it will work but ask the insurance supplement plan F to provide the policy language as to why you are turned down
I have a HumanaChoice PPO and had no problem getting a PSMA Pet/CT scan.
Don't forget you want an fdg scan to accompany the psma scan.
Does Medicare also approve that fdg scan for a newly diagnosed high risk man?
FDG scan?
Original Medicare ,like your dad has, doesn’t have many prior approval requirements so I might ask the provider first why, how they submitted a request…unless you see it on the following list, which I didn’t at first glance. Ask what code they used. Please let us know what you learn and how this was resolved we are all learning with you.
I have United Healthcare Advantage PPO plan and my PSMA scan was approved without having bone scan or MRI
OMG, IMHO that is not a substitute for a PSMA scan!
I so wish that America had proper single payer health care... I'm a veteran with the VA provided health care. My doctor wants a test, procedure, whatever: I get it, no questions asked! No profits first before the patient's health and wellbeing.
This crap makes me so angry!
I literally just went through this. Denied me twice. Finally got approved yesterday. I attached what they sent me.
I was diagnosed a few months ago as very high risk with 12/12 cores G8 and G7. After reading here and other sources how sensitive and targeted the PSMA Pet scan is for prostate cancer, I was advocating for it pre and post diagnosis. After my diagnosis at MDA, I returned 3 weeks later for a bone scan, abdomen CT, and PSMA pet scan. The doctors at MDA indicated that the PSMA test has it's place, but that they generally get more information from the bone scan and CT at that point in my diagnosis. My scans were all clear, but with 5 g8s, total involvement with the prostate and a couple of suspicious pelvic nodes, treatment is/will be 24 mo adt and proton treatments to prostate, seminal vesicles and pelvic nodes.
Medicare and my plan G medigap have covered everything to date, including the psma test. I don't think medicare always approves a ~$20k psma test as a first line diagnosis tool, thus the bone scan and CT first. I don't think medicare is the issue with your coverage, but the way it was handled at UC Health in Denver.
You may need to move to a different health care provider and choose somewhere that routinely does the PSMA test with medicare patients. By the way, medicare covered all of the psma costs and my medigap plan was only responsible for only about $325.
Definitely make sure he hangs on to that traditional medicare plan and you won't have any insurance underwriters dictating how you go about treatment of this disease. Many folks here and other forums recommend going to a cancer center of excellence for treatment and with traditional medicare you and your dad can choose wherever you want to go for treatment. I'm traveling 500 miles for my care and it is expensive and a hassle, but worth it to me.
cancer.gov/research/infrast...
If you don't mind me asking, what ins. co. is your medigap plan with? And who do you see at MDA?
My medigap plan g is with mutual of omaha. At MDA my urologist is Dr. Pettaway, MO is Dr. Corn, and RO is Dr. Frank.
My cousin, a retired MD, explained to me how she studied the latest research regarding her cervical cancer and selected her doctors (also at MDA) from the research papers she was reading. I merely studied the bios on the MDA site and made appointments with both Dr. Corn and Dr. Frank after my diagnosis, so I sort of picked out my "dream team". At MDA, like most university-based facilities, these are busy doctors, not only seeing patients, but doing research, teaching, writing papers, presenting at conferences, and running departments.
Insurance companies apparently like living in the dark ages. Looking for mets with a bone and CT scan is like take a high quality picture with a throwaway camera when you have a Super High Def Nikon in your back pocket. I just got rejected myself, and it was actually fun letting them know how out of date they are.
I was able to get a PSMA Pet scan at UC Health in Denver. Medicare approved. I did connect with UC Health insurance submitter prior to scan to confirm coverage. (Without prior mri or bone scans)
Glad I got scan done, as pelvic lymph node and rib hot spots were identified.
Good luck!
Appeal. When my Community Care HMO denied I wrote a letter of appeal and my oncologist wrote one too. Don’t sound mad in the letter, just explain the test is critical for your doctor to evaluate your treatment. Good luck.
@ superb floor: I also use University of Colorado Health in Denver. My insurance is United Health Medicare Advantage PPO. So far, that insurance has paid for everything including ADT med I've been on, Orgovyx. I meet with my urologic oncologist this afternoon and will ask about the protocol for PSMA scan approval. I've not had one yet but will soon given my PCa recurrence after an ADT "vacation." (I am also Gleason 9.) FYI, UC Health has had some billing and insurance issues lately due to their bifurcation into UC Health and CU Medicine. CU Medicine often has insurance coding issues, probably due to their inexperience in dealing with insurance.
thank you - very much appreciated
You indicated your Dad doesn't have Medicare Advantage or a PPO, so what those plans cover is irrelevant for him.
Your Dad appears to have Medicare and Medicare Supplement (Plan F in your State). As others have suggested, check with the Hospital as to what they are up to.
It's definitely a covered test by Medicare. I'm surprised it even required pre-authorization.
Typically Medicare only requires Pre auth for DME (Durable Medical Equipment) and Prosthetics and some medications may require it, but your Dad's issue is none of those.
thank you - it is very surprising to me based off all the feedback I’ve received. My dad received a call from an RN today who told him the test was only relevant if the cancer was localized and the bone scan / CT scan was more important which made me lose a lot of confidence in the hospital. We’ve sent them a detailed message with appropriate billing codes for Medicare and hopefully will hear back from them soon. Otherwise I think we should just pay for the test ourselves and deal with this later.
Where's your Oncologist in all this. He/She is the ordering physician and should be the only one you need to go to for help on this. Can we assume the RN works for your Oncologist and not the hospital? If it's me, as your Dad's advocate, I would be talking to the oncologist and have them sort it for you. Having said that, it reads like your Dad had a biopsy. If it was an MRI guided biopsy, they could tell you if the cancer was inside the margins (remained inside the prostate). If it was a standard ultrasound biopsy there is no good way too tell without a scan (MRI, PET etc..)
this was a standard biopsy done at a urology clinic - they clearly were not qualified to treat a patient fitting my dad’s profile so I pushed to get him into UC Health, which I understood to be the best option in Colorado. Thus far he has only met with a surgical oncologist at UC Health (who will not be his provider longer term given disease advancement + age) so the problem is likely that we do not have a MO involved at this point.
Next appointment with supposedly a full treatment team is next Friday 10/14 (assuming these Medicare issues / bone scan results don’t delay things further) and I *assume* a MO will be added at that point who can better help us through this process. I live out of state (east coast) so am limited by that but will be there for his appointments.
Right now the only plan is bone scan / CT scan this Friday 10/7 followed by an appointment with the treatment team 10/14. I am pushing to get a PSMA PET done prior to that appointment whether we have to pay for it ourselves or not. Original diagnoses was early September but with having to go through his original clinic + setting up new appointments with UC Health this has been dragging on for too long.
Same here and concur with Explorer08 about coding/billing issues. My MO at UCHealth -Anschutz had to personally contact my private insurer (Anthem BlueX) three times to “appeal” 2 prior denials. Finally got it through on the 3rd try and had the Pylarify/PSMA scan last month.
I asked for an Axumin scan rather than the 2nd biopsy my urologist proposed. Insurance required another round of CT and bone scans before they would approve the Axumin scan. They also required that PSA show a history of consecutive rises. I did eventually get that Axumin scan. I am on a supplmental plan F insurance plan.
We went round and round with the MO at UC Health when I wanted PSMA instead of CT and bone scan for reoccurrence and failure of first line ADT. MO said he was having problems getting PSMA scans approved, even with Medicare and supplements. After a video conference call with MO we decided to let the PSMA battle go because, regardless of what it showed, it was not going to change next step. One thing the MO was concerned about was, if he needed to order new scan within a short timespan he might not be able to PSMA approved and he wants to be able to have baseline to compare apples to apples. I do think this is a UC Health issue. When I asked my contact at Rocky Mountain Cancer Center about getting a PSMA scan there (because that's where my husband had salvage radiation and they wrote the order for him to get PSMA scan at UCLA before it was FDA approved) she said they were not having any problems getting them approved. I would tell them to appeal it and if they won't, ask if they will write an order for you to go get one at Rocky Mountain Cancer Center. This is frustrating, but I do believe other than this issue, UC Health is top notch.
thank you very much - really appreciate the sharing of your experience there
my doc said they always deny it initially and the doc did an appeal for me before I even knew it was denied. which went through easily to approval. If you have not pushed doc to help you appeal yet that is the next step.
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