Denied PET Pylarify by Kaiser

[treedown]

Kaiser denied my PET scan today because my PSA hasn't hit 2.0 above nadir yet on 2 consecutive tests. I am not surprised. I'll probably hit it in a few weeks when I get my next test so I guess its just a matter of time. I have to wonder what the benefit of conventional tests are at this time but I guess their an option. My MO is pretty sure its to soon for anything to show up on them. He will appeal the PET scan, so maybe it will get resolved in time for me to still take the Feb 6 PET scan I scheduled yesterday. Or it will get pushed back until my second 2.0+ PSA test.

[dico]

My husband's PSA is currently undectable, yet he was approved for a Pylarify pet scan (to be done in a couple of weeks). The doctor wants to confirm that he is still in remission but decided early on that his PSA was not a good indicator. I don't pretend to understand why some scans are approved and others are not, but it is very curious.

[treedown in reply to dico]

Thanks, I think if your husband is undetectable than there is no point in any scan other than that one. My MO called and as we suspect it will only take a few more weeks to meet their criteria than that will be the plan. If I plateau below 2.04 we will need to decide how to proceed.

Best of luck with your husbands scan.

[Tall_Allen]

Pylarify was proven to be useful in biochemically recurrent men (and high-risk untreated men), which is why it is only approved for those circumstances. I think Kaiser will allow you to also get an mpMRI, which may prove to be useful if your recurrence is intra-prostatic.

[treedown in reply to Tall_Allen]

Thanks, my MO did discuss a MRI based on the result of the PET scan. As we are both pretty sure my PSA should hit the mark on the next test and scans are into February anyway we would proceed and just push it back a few weeks. He is also pretty sure the cause of the increase is outside the pelvis, he mentioned 70%. I am hoping that he's wrong but not completely sure that will make decisions any easier after all the radiation I had there. I have been reading you papers on how to proceed after failed EBRT which will be a big help once I know for sure where the cancer is.

[Tall_Allen in reply to treedown]

Please let me know.

[MateoBeach in reply to treedown]

appeal it and push for the scan. It does not need to be nadir + 2.0 in order to be diagnostic for identifying sites of remaining cancer. Typical for Kaiser. 😣

[Hidden in reply to MateoBeach]

My insurance' requirement for an Axumin scan was three PSA readings showing increases. My PSA was below 2.0 when I got the scan.

[treedown in reply to Hidden]

Sounds like you have better insurance than I do. I know that 3 consecutive increases is/was by some also a definition of recurrence. Did your axumin scan find anything? I could have pushed for scans earlier but my deductible would have kicked in December so decided for that reason as well as the hope it would plateau under 2.0 worth waiting until my prescheduled January MO appt. My velocity did slow down on my last test so I hope to see a new trend. I do wonder why they decided 2.0 is relevant as a definition for BCR after radiation but was aware it is the current definition. I wonder what I will do if it plateaus at 1.99 :0)

[Hidden in reply to treedown]

I have AARP Medicare Supplement Plan F with United Healthcare. My PSA seems to have plateau'd at 1.8 but I have to sweat out my next PSA reveal in less than a week. My axumin scan in Dec 2021 revealed nothing of concern. Been in this fight since diagnosis in 2016.

[treedown in reply to Hidden]

Yes your plateau of 1.8 is something I have been aware of and had in the back of my mind though I did not associate it to your forum name. Your not on ADT correct?

[Hidden in reply to treedown]

That is correct.

[TJGuy]

Health insurance companies want to avoid paying for treatment especially higher cost scans. They are interested in their bottom line not your health.

So after primary treatment by radiation to the prostate gland, recurrence is defined by a PSA rise of 2.0 over Nadar witch was <.04 for you. So when you exceed 2.04 once, and then again, meaning twice in a row your considered to have recurrence of PC.

What time interval have they required between PSA tests if any. Is one month acceptable? I would assume so.

Have they mentioned first requiring CT scan and bone scan before a PET scan? This is now becoming common and is often another ploy I'll call it in cutting down on the number of scans they approve. Just more barriers with the hope they can deny you better care because of its cost.

And if you travel for care this can mean multiple trips adding greatly to expenses. In that case you might get these nuisance tests out of the way at a local facility and get the PSMA test and it's evaluation and your next care plan at your cancer center hospital.

Glad your using ultrasensitive PSA tests, these give you a earlier indication and lower value to determine recurrence.

I really dislike people using the word undetectable for PSA test that go only to 0.1 There is the capability to measure to far less that.

Most PSMA scans will find PC at 2.0 so good luck.

This raises a interesting difference, in that if you have a radiated prostate, I guess your forever using a PSA of greater than post radiation Nadar plus 2 to define recurrence. Where as if you had a RP your forever using >0.1 to define recurrence.

So for RP patients, insurance is usually requiring a fixed value of PSA1.0 or greater now for approving scans.

And for Radiation as primary treatment the PSA value of 2.0 plus nadar is determined for each patient.

[Cooolone]

Most any scan will see something at PSA +2.0ng post therapy... This is subjective of course and although the threshold may have been established by trial data, I wonder "Who" arbitrarily makes that decision as to the individual benefit by patient diagnosis and risk assessment!? We aren't numbers or a group, we are individual(s) who have cancer, and every single one of us is different. In a recurrence setting, the oncologist should be the person making the determination as to medical necessity, not insurance. If the doctor writes the script, that should be the end of it. And if artificial guidelines are established, outside study data, well then that's when it's important to roll up the sleeves and make some noise. Make the calls, ruffle feathers... The squeaky wheel gets the oil!

Best Regards

[FRTHBST]

From the discussion it sounds as if you will be getting the PET scan soon. So all the best with information gained and next steps in treatment. I don't know your insurance situation with Kaiser, is it an example of an advantage plan second guessing your Drs on best treatment options?

[treedown]

As I started typing a message to my MO, he called me. As the scan isn't until Feb we will wait until my next PSA test in 3rd week of Jan. As I suspect it to be above 2, if it is, we will wait 2 weeks and take it again. The only anomalybased on my calculated 1.3 month doubling time was it slowed to 2 months on my last test. Assumming that is still the case, then it will be 2 on my next test and we can resubmit to Kaiser. Should only delay the scan a couple weeks. If denied then we will appeal.

[maggiedrum]

I know this will put a target on my back but I have to give at least a bit of support to the decision making by some insurance companies. It's been a long time since I had Kaiser but they always would do anything and everything to treat me if they thought it would improve my chances for worsening of any disease I had (specifically Hep C before there were any cures like I have had in recent years).

Other insurance companies will do what you suggest in that they are just protecting the bottom line, especially since many hedge fund and other cash/profit centric companies have been gobbling up medical insurance companies, doctor clinics, and hospitals. They cut costs and pare back care to the bone.

In many cases though, the companies do, in fact, stay up on the current state of therapies. Many times (and I have appealed and won on a couple of things) the therapy the patient wants has only been approved, or shown to be effective, at certain points. If a given therapy has not been shown to be effective then they will be reluctant to pay for it, especially if it is very expensive. And, two different doctors can believe a therapy would or would not be effective and warranted for a given situation.

In your case it may well be the best treatment. I wish you good luck in getting your appeal through if so. It's entirely understandable to advocate for yourself based on what you have learned here or from your doctors. I just wanted to say that all insurance companies are not out to gouge their customers. And not all doctors really give the best advice. And not all members of this forum give the best advice either although this is a wonderful resource with some crackerjack people who are up on the latest and greatest, and, in some cases will give an opinion that may go against what a man with PC may want to hear. Kudos to them.