Husband was DX with prostate cancer. PSA 88. He is 58 so don’t qualify for Medicare yet. Doctor put in order for PSMA PET scan for husband and BCBS denied. We will appeal. I’m sure they won’t approve until we do a bone scan and MRI. He already did CT and it was clear. Since we have a high deductible plan anyway (up till now we both have been healthy) does anyone know of locations we can go to pay out of pocket that would be less than $7600. That’s the price we were quoted if he pays for it himself.
PSMA PET scan: Husband was DX with... - Advanced Prostate...
PSMA PET scan
I think you can gat one for around $4000-$5000 at the hospitals here in New England. Dana Farber, Dartmouth, etc. You can get an estimate on line.
We went straight to PSMA PET because that’s what the urologist suggested. Due to high PSA ( he said he has only seen that number a few times)In his defense, I think he is trying to go for what he feels will do the most good. Unfortunately the insurance is shooting it down. We were hoping his voice in the appeal process ( he said he did a peer to peer but it was still denied)could justify it due to the fact that the PSA is so high. At this point, I think we need to go ahead and get a MO on the team at a cancer center/hospital since we will possibly need to get bone scan, MRI anyway before PSMA PET unless we are willing to pay out of pocket now.
In my opinion, any guy who has prostate cancer should have a medical oncologist on his team.
When my husband was first Dx'd in Nov, his urologist referred us to a medical oncologist (which you need) right away, telling us that insurance generally WILL NOT approve a PSMA ordered by a urologist. Get a referral - the ultra-sensitive PSMA will tell you everything you need to know about where the cancer has gotten to (or not - fingers crossed). This impacts treatment decisions. Good luck.
No scan is capable of confirming there is no cancer.
Finding an MO is not a bad idea if you can afford it. They're office may know the magic incantation to make the insurance company disappear.
Received appeal paperwork in mail today.
it’s pretty simple. Go with the system unless your font need money...... If you must have a bone scan first, then just do it,,., I wish you the best.
My husband's bone scan was clean. The psma showed two mets in the sternum. With a psa that high, isn't it better to go straight for the psma in order to start treatment or, hopefully, find out there us no need for treatment ? Why waste time on the bone scan?
Barnacle I can’t answer your question. I just know the each diagnostic test enables your physician to treat. In so my opinion is that I can only share the diagnostic testing I have received since 2004 for metastatic prostate cancer. Times have changed. I started in research and academia and not the community at large. Bone scans are tried and true.
On my case since I have available scans with which to compare evidence of disease, it was used after my first PSMA PET was negative. After the bone scan was negative for reoccurrence of distant Mets, then a the only place left was a MRI of the prostate.
It a step process that both the medical and insurance community follow today. And, both are aware of the costs. However, if one desires one of a new test jumping ahead of tried and true, then that is possible as an out of pocket expense.
We thought Australia was expensive! Compared to U.S. we are cheap. India and Thailand offer world class scans far better priced than U.S.
I got my PSMA scan free, through an Astra Zeneca-funded trial. (In Rockingham, Perth, Western Australia).Everything else I get on our great public health system. My meds cost me next to nothing, now that I'm on the Age Pension.
I'm glad I got cancer in Australia! 😉😳😀👍(Yes, I am making a joke!)
we had to pay $700 psma pet in 2017 plus $450 mri. Not covered then by Medicare. Yes we are fortunate in Oz. 🌻
Just had one done in Cincinnati area and the cost to me was just $113. With new technology, those who are first in line are paying for the R/D.
To BluesmanNick and babychi,
But I understand the prerequisite is, having a one night-er with a wooly sheep.....and then guessing the sheep's correct gender.
Good Luck, Good Health and Good Humor.
j-o-h-n Sunday 03/05/2023 10:53 PM EST
New Zealand has the sheep. Not Australia. We have the kangaroos.
Yeh, like wot 'e said. 😉👍🐨🇦🇺
A-ha, your Roos are quite clever, they dress up like sheep.....(better to hump than to jump).....
Good Luck, Good Health and Good Humor.
j-o-h-n Tuesday 03/07/2023 2:13 PM EST
I'm not an expert but if the CT scan is clear, it seems likely the PCa is localised to the prostate. I would have thought an MRI of the pelvis a good next step. Have they started you on ADT yet?
does the high deductable plan pay 100% after you reach $7,600 ?
If yes, then you might as well go for all 3 scans. It is still early in the year and ongoing care can be expensive. Prostate surgery, or radiation treatment will likely be recommended after the scans. Adding both a RO and a MO to your treatment decision team would be a good idea since each speciality brings a different perspective to the preferred plan
Good luck killing the cancer now with initial treatments
The high deductible plan pays 70/30 after you reach deductible of 6,000. We haven’t reached it yet but with the tests I’m sure it will be soon. The 7600 is the cost of test ( at one facility- will shop around) if we pay out of pocket ourselves and not use insurance.
then I would push for exception and try for the single scan. I hope you are successful.
Even more, i hope the scan provides good news and the cancer is very small and local.
If the ins company denied the scan, the cost won't count twoards your deductible if you pay for it.
please go to Oncologist. Urologist should have told you that right away. Wife to wife
Push on the appeal. Wishing you the best of luck and outcome.
we have BCBS and my husband just had a PSMA scan done in Louisiana. We have not received a bill yet and paid nothing up front. I’m sure we will have to pay at least the deductible, but at least it wasn’t denied. Our MO ordered the scan. I think if they word it that the results will change the treatment plan and it is not just for information it will cover it. Also, it was for a recurrence of cancer after treatment. That may make a difference as well. Good luck!
I would do whatever I had to to get the PSMA Pet scan. I went through the regular process, MRI, CT, Bone Scan, 4 digital exams. After the digital exam had several doctors said they couldn’t feel anything, got the call that said “Good News! Nothing showing on the bone scan!”
Then I got the PSMA Pet Scan, had an initial PSA of 7.4. Get the call that said that “Your Seminal Vesticles were a lot more involved than we first believed and that there was a small bone metastasis on the T2 section of spine.” This information moved me into a different category of patient and I am now considered Oligometastatic and instead of radiation just to the pelvic area and 24 months of Lupron I now have radiation to the pelvic area, SBRT radiation to the one T2 metastatis, Lupron and Erleada which I will apparently have as long as it is effective.
Essentially, I got a much more precise evaluation of my PC and am getting a better treatment than I would have gotten had I just gone with the traditional methods. My doctor says that it is hard to judge just how much more effective my treatment will be as I am now in a new category of patient that has not been studied. That is, not Oligometatastic under the old methods but moved up in class of patient due to the better PSMA Pet Scan.
That being said, I am 69 and have good supplemental insurance, It didn’t cost me anything.
In the future, I believe that Doctors/Insurance companies will just go straight to the PSMA Pet scan as it is so much more accurate.
He has had CT scan and biopsy done. After the biopsy is when urologist ordered the PSMA PET. Fortunately he is an active runner and work out at gym weekly.
With a PSA of 80+, what makes the doctor, or you, think the super sensitive scan will see anything other scans won't? Other than possibly smaller lesions due to the sensitivity... But the presence of disease while more than likely be revealed by the SOC of MRI, CT and Bone scan.
I keep finding posts and threads like this which associate the PSMA Pet scan as some miracle scan that is 100% proof positive and fool proof. I understand with all the hype surrounding it, but all scans have their places and proper use. The real question should be is there an advantage to using this scan right now for you over the use of other scans? You may save yourself some anxiety, both in diagnosis and in finances, of your team would impart realistic expectations to you of the diagnostic process. Unrealistic expectations creates much of our dissatisfaction, remorse when it comes down the line to treatment. But treatment will be based upon as accurate a diagnosis we may receive. Here, in my opinion, a patient opinion, I don't believe the PSMA Pet scan offers an advantage over the standardized testing.
That all said, I'm not sure how your insurance works where you are, but back a few years ago when the PSMA-PET Scan wasn't yet approved and I was scheduling one for trying to determine persistent PSA post RP... My discussion with the care team and then insurance was able to separate the fact that the difference between a CT and the PSMA was the contrasting agent being used (simple) and was able to get a pre scan determination that my coat would only be the cost of the agent, about $1800 at the time and they would cover the other costs. Point is, hit the phones and hit them hard... If you want to try for the scan, sometimes you can get individual attention and approval. For me, it worked out at the time I qualified for a study and received the scan for free, a benefit of getting to a Major Cancer Center and one rated in Excellence that do a lot of research and have access to trials and such.
Just sharing some thoughts and the hope for your success!
I would heartily agree with Cooolone here. I found an excellent paper written by an MO and radiologist about the pros and cons of the two types of PET scans. I had a couple of PET/CT scans initially and a bone scan. The first bone scan was right after my prostatectomy and my PSA remained low even though my PCa was aggressive and out of the margin of the gland. MRI with contrast and the PET scans did not detect any mets.
My PSA continued to rise (I am not on any ADT or radiation therapy due to serious side effects). My MO decided to recommend the PSMA scan and it found several lymph nodes with the cancer, spread out in from my groin to my shoulders. Small and by themselves not a good indication of really serious, immediately disastrous, metastasis (although plenty scary).
My PSA continues to rise. My MO said that subsequent PSMA scans would not be significantly better than a regular PET/CT scan as the micro imaging would not give any additional info for therapy (in my case but I believe in others as well). I initially argued about it but now I see the reasoning and I'm happy with it. If you were going to have targeted radiation in one localized met where you need to be very careful about the amount of radiation and if it might damage any close by tissues, then the additional precision might be useful but I am not qualified to give an opinion on that.
If it were me, I would reserve the PSMA scan until after an indication of a met or mets have been found with a bone scan and/or a PET/CT scan.
why not first ask for an fdg pet scan before psma pet?
Good question- keep in mind we are new to the game and still learning but we knew enough to ask that question - we were not given the answer. Will be requesting all reports (pathologist, etc)on Monday.
70 now, have been on this journey for now three years, heading to salvage RT next month, RALP jan 2022, slow rising PSA since. i found PCRI website and heartily offer this site as added reference. heaps of info on youtube videos from their symposiums. good luck and God bless yours and all of ours journeys on this fight....
Thank you for sharing. It’s appreciated. We are learning so much and as a wife, I want to assist my husband in whatever way I can. Much of that is doing research and sharing since I have a little more time than he does.
In my case, my first PSA was 99 in June, then 116 in August, then 186 in late November. Finally had the PSMA shortly after the 186. Going through the process took about 6 months - multiple doctors, scheduling, etc...wish I would've been able to cut to the chase with a PSMA in June. Advice- don't wait/shop around too much.
It may be useful in your appeal to review the NCCN guidelines, if appropriate, cite them. - jnccn.org/view/journals/jnc...
I should add that my treatment didn't start until after the PSMA.
UCLA may have a program. It was $3,500 in 2021.
Thank you. They are on my list to call Monday. So good to have options - especially if this appeal process drags. We actually already have a trip planned to go to Cal soon.
Not any more The Pylirafy scan which is readily available is $8000 and that is the scan of choice at UCLA. I had a ga68 PSMA PET scan at UCLA in may of 2021 and it was $3200
I asked my RO and he could not explain the increase. Also other expenses such as a zoom consultation have gone up by 25%
Once the scan or any scan is FDA approved the cash price is no longer available.
Yes get in to establish with MO, and consult with an RO at the same high level center, if possible. He needs to know if he is already metastatic at diagnosis (“de novo”). The MRI is reassuring but not sufficient. Get the bone scan promptly and CT too. If either of those show widespread metastasis then he can move to intensive systemic treatment.
If not, the PSMA scan may still add more information so he should get that along the way, especially if the bone scan is negative.
. But he should be planning for definitive primary treatment: either RARP (robotically assisted radical prostatectomy or radiation IMRT to the entire prostate and probably also to the pelvic lymph node fields. Personal choice with similar rates of “cure” but possibilities of significant side effects with either. So needs to be explored. RARP is very technique dependent so must have a surgeon that has done hundreds and is very skilled, not a urology resident or general urologist. Best, MB (Paul)
Is your husband a Veteran?
I agree that you should find a good MO immediately and let the MO take over. Urologists seem to want to hang on to the patient long after a cancer diagnosis. I had to jump ship on mine.
I was denied the best scan available in 2019 the Axumin. My Drs convinced me to not pay out of pocket because it would not change my treatment which did not make since then and still does not. Anyway I am recurrent and had to have CT and bone scan before insurance approved by PSMA scan. As expected by all except the insurance company it found what the what the others did not.
It's a damn shame you were denied. You are such a nice guy.
Thats what I said, but they said too bad.
Hey Dimples 👋...
Short version: Sometimes the person reading the CT scan might "miss" it😡.
Slightly Longer version:
My FIRST CT scan was read by someone who also said no cancer was found. When I later went for a second opinion on my treatment, the 1st CT scan was not sent to him to review so he asked for a new CT scan (long story). The person who read the new scan picked up on it.
You and your husband get hit with a lot during Dr visits. It's easy to miss info. If they have a "Patient Portal" you can often read results before your follow-up visits
Remember, we are all here for you!
My insurance denied by PSMA until I had negative bone and ct. Then my RO re applied and it was approved.
Following radical prostatectomy had a PSA of 12 and rising. PET/CT and bone scan were all clear but I wanted to know the extent of metastatic involvement. Got the surgeon to give me a referral to Charité International Healthcare in Berlin for full body GA68 PSMA-PET scan which cost E3,450.00 which included a full hour consultation with Head of Oncology Dept. Travel and hotel cost not included but had a good time exploring Berlin.
Scans showed two lower pelvic lesions and nothing more which was good and suggested the metastasis had probably occurred prior to the surgery. On return to Canada had standard prostrate bed 35 sessions of radiation therapy. In retrospect I would have found a hospital to do SBRT which is reduced number of sessions at higher dosage and from what I have read better long term outcomes.
Strongly suggest GA60 PSMA-PET scan as first port of call to know the extent and location of all prostrate cancer for a much better insight into treatment and therapy options.
Best of luck
Please keep a folder with paper report, CD discs of image.
PSMA is very sensitive will detect PSA change 0.2 ng/mL.
CT and bone scans could be negative because level of sensitivity, PSMA is the most sensitive.
NCCN - has a patient information -benefit of it has explanation of medical vernacular, print it and as reference .
The more you know and understand the better it is, you could ask meaningful questions and help your husband.
i just had a scan at Mayo Scottsdale - Mayo charged $16k but medicare paid $6700 and Mayo accepted that. You would hope that you could get the medicare price by paying cash - but I don't think they play that way
AETNA approved my PET Scan. Post treatment recurrence in my case.
check out TAF.org
Depending on your income level, the fund can provide great help covering the financial burdens
So typical of insurance companies. What was his gleason score from his biopsy? T of hat combined with the super high psa should be enough to require the PSMA scan. This is becoming more of a problem with insurance company denials. jnm.snmjournals.org/content...
Research the effects of Fenbendazole on cancer cells. Check out the FB page on Fenbendazole.
So where are you located?...... I don't mean your dimples........ I meant you two...
Good Luck, Good Health and Good Humor.
j-o-h-n Sunday 03/05/2023 10:43 PM EST
Just text something to you please your husband has prostate cancer he needs to see a Oncologist. My husband urologist Check his prostate and it came out cancer yes he then said you need to go to Oncologist!
why not just get the bone scan first?