Pre-approvals under Medicare

[dhccpa]

I have regular Medicare plus a supplement and Part D.

I'm just starting to research this, but figured many of you have already dealt with this issue.

Does Medicare (not Medicare Advantage) do pre-approvals for things like Provenge, chemo, PSMA PET scan, etc.?

None of my medical institutions seem to seek pre-approvals, but before moving farther down the line, I'd like to get clarification, including how to get (preferably) written pre-approval on some of the more expense, iffy things.

For example, my two main oncologists are wanting me to do a PSMA PET, but it would not change my treatment presently.

Any details on best way to seek pre-approvals would be helpful.

Thanks.

[tango65]

Medicare, without an insurance company in the middle, let's called direct medicare, does not pre approved treatments.

Once the treatment is done and they receive the claim, they decide based in medical necessity only. They don't necessary follow the FDA guidelines for a particular treatment.

I received Pluvicto treatment even when I never had chemo.

If a treatment is not approved you can appeal (your doctor) explaining why is medical necessary if they agree they will pay.

[dhccpa in reply to tango65]

That sucks, but it's what I feared. Have you ever been stuck with a bill for something that wasn't approved?

[tango65 in reply to dhccpa]

No, they always approved all the treatments.

When I had the first Pluvicto it was a difficult decision since the cancer center charges around 240K for the treatment. Incredible.!!!

I look around and finally I got in touch with the company administering Medicare for the area where I live,

They told me that I had to have the treatment and if it was medical necessary they will pay.

It was very stressful, but at the end they paid.

[dhccpa in reply to tango65]

Whew! I think that bill would induce some stress.

Thanks for your input.

[Concerned-wife in reply to dhccpa]

Read about ABNs which are designed to protect you. webmd.com/health-insurance/...

[dhccpa in reply to Concerned-wife]

Thanks I'll take a look.

[rsgdmd]

My understanding is Medicare covers all conventional treatments, including Pluvicto, PSMA PET scans (4 per year), etc.

[dhccpa in reply to rsgdmd]

Thanks

[leebeth in reply to rsgdmd]

This is accurate, except that my husband was not restricted to 4 PSMA PET scans annually. He had 7 in 2022. Completely covered.

[dhccpa in reply to leebeth]

Wow! Now that surprises me. Your doc apparently documents well!

[TeleGuy]

My understanding is that if your doc (or institution?) accepts “Medicare assignment” they can’t balance bill you. Only once have I been asked to sign an agreement saying that I would pay if Medicare didn’t.

[dhccpa in reply to TeleGuy]

Thanks. I've had to sign those, and they're frightening (scans, for example), but Medicare has paid so far.

[swwags in reply to TeleGuy]

That's a different discussion. Balance billing refers to the difference between what Medicare paid and what the doctor would have charged you without Medicare. Completely different than pre-authorization.

[Retireddoc]

If a procedure/treatment has been FDA approved and your Oncologist believes it is medically necessary, it would be rare for Traditional Medicare to deny payment. Appeal would likely be successful. That's why I opted for Traditional Medicare rather than Medicare Advantage; a lot less red tape and no pre approval.

[dhccpa in reply to Retireddoc]

Thanks! Yes, my agent told me he would NOT sell me a Medicare Advantage plan, saying he couldn't sleep at night! Then he explained the reasons.

[JD-guy]

While you all are discussing Medicare, I have another question, if I can inject it here? With traditional Medicare do you have co-pays on treatments, office visits etc. I will be needing to sign up towards the end of this year. I do not know very much about how it works, I am trying to read up about it. By what I read on here I do not want Medicare advantage, with my advanced Prostate cancer. Currently I am doing Lupron, Xtandi and Exgeva. Plus BP meds nothing pricey.

Thanks

Keith--jdguy

[Concerned-wife in reply to JD-guy]

Medicare.gov has lots of educational info as well as tools to help you select a supplemental plan and a drug plan. Be especially careful selecting the supplement..in most states they are underwritten and impossible to change.

[Tommyj2 in reply to JD-guy]

Yes there is a 20% copay with Medicare and if you have prostate ca you are going to want to purchase a supplement to offset that copay which can get pricey with some of the treatments and scans…..get a supplement quickly….you don’t want to miss the window where you are guaranteed acceptance…….later they can refuse you due to a pre-existing condition.

[dhccpa in reply to Tommyj2]

I already have a supplement.

[dhccpa]

If you get traditional Medicare, you also need a supplement policy to pay the remaining 20% of provider costs. Without the supplement, you will have to pay 20% of costs other than being in a hospital. I've never had any co-pays for anything else (yet). You also will need a Plan D pharmacy plan for Rx drugs.

[JD-guy in reply to dhccpa]

Ok, thank you, that helps me understand, with the other information that I have.

[85236442968]

dhccpa

Congratulations on not falling into the Advantage plan trap.

While a supplement is a bit higher priced and does not have all the extra items that an Advantage plan has, an Advantage plan is still an insurance policy with all of the co pays and fees and preapprovals that an insurance plan has.

You will learn that your Supplement has none of that stuff other than an annual co pay of $240 (for this year/2024) In a personal note I have a Plan G, from AARP/United HealthCare.

There was a dispute about my first Pet Scan, but it was somehow due to not being entered correctly by the hospital. (you would think they would have this down pat)

In the year 2023 and so far in 2024, Medicare B and my Supplement covered everything that was done, MRIs, Biopsy's, Pet Scans, radiation, Dr visits, everything.

You did not say what you have for a plan D (Drug Plan). there are a lot of posts here that talk about how to help with drug costs, both chemo and ADT. Good RX, Single Care, Cost Plus (Mark Cuban) and a number of other companies can help with drug cost above abd beyond you Plan D. There are also non profit foundations that help with co-pays that can be accessed via your pharmacy,

[dhccpa in reply to 85236442968]

Thanks. I have a good Wellcare Plan D. And I also use GoodRx and Singlecare as well.

[EdBar]

I’ve always asked my providers if treatments were pre approved by Medicare they all said yes before proceeding. I’ve had all the treatments you’ve mentioned in your post.

Ed

[swwags in reply to EdBar]

I use a similar tact. I tell them if Medicare doesn't cover it, I decline the treatment. I think the time has passed where providers used to stick you in the middle of the pre-auth wars. They pretty much leave the patient out of the discussion.

[dhccpa in reply to EdBar]

Thanks very much.

[Teacherdude72]

You really need to get an Advantage plan. Better coverage and often no monthly fee.

[dhccpa in reply to Teacherdude72]

Most say the Advantage plans are too restrictive. It may vary by plan and by state. Are you in a network?

[swwags in reply to dhccpa]

Medicare advantage is private insurance. It doesn't have better coverage. They often require pre auth, depending on plan, carrier, etc. which is your question. If you have doctors now, ask them who they'd rather work with. Medicare is a National Plan and has a national network. Medicare Advantage is privatization of your Medicare benefit.

[dhccpa in reply to swwags]

Thanks--yes, I've been on regular Medicare with supplement since starting Medicare in June 2021. No problems thus far.

[StayingOptimistic in reply to dhccpa]

Which company you use for supplement insurance? I need to get one. Thanks

[dhccpa in reply to StayingOptimistic]

United Health. I'm in Florida. Your state may have different choices.

[j-o-h-n]

Just speak with a foreign accent and the government will treat you like an illegal alien and all your bills will be paid by YOU and Me.

Good Luck, Good Health and Good Humor.

j-o-h-n