trouble with insurance denial of PSMA scan

[joeguy]

has anyone else had issues with their insurance denying PSMA scans ? Blue cross blue shield is claiming PSMA scans are only authorized if you are planning to have treatment with Pluvicto. I have already been through Pluvicto (and failed) and I did have a PSMA scan before starting and after, but now that I am back on chemo with questionable results, they are denying any further PSMA scans. Will be doing an FDG pet instead, which should answer some questions about why Pluvicto failed, but may not be as good as a PSMA PET.

[pjd55d]

try this:

if your Doctor wants a PSMA, have them write a brief letter to the insurance co telling them WHY the Dr wants it - might get approved

worked for me with another med issue

something else you have to spend time and energy fighting for

years ago a friend said: " you have to participate at a very high level to get the medical care you need " - lots of truth there

good luck

[joeguy in reply to pjd55d]

Very true…,

[fireandice123]

For my first PSMA scan Blue Cross initially refused to approve it. My MO talked to them and they agreed to the PSMA scan if I first got CT and bone scans, again. Those were my third such scans. My MO didn’t really understand why they wanted that but we went ahead with them and they paid for the PSMA scan. I had no problems getting them to approve my second PSMA scan. I’ve never had Pluvicto.

[MoonRocket]

I have Aetna Pos II plan thru my employer. Had my first PSMA scan in May 2022 after my BCR. Findings were negative. I asked my MO after my October 2024 if new scans were warranted and he agreed and he wanted a PSMA scan. Insurance approved it in 2 weeks and I got the scan 2 Friday's ago. So it is possible to convince the insurance to approve. The MO just needs to justify it.

[joeguy in reply to MoonRocket]

will probably have to wait till PSA starts rising again to justify the scan…. It’s fairly stable at 17 right now

[dhccpa in reply to joeguy]

That sounds high enough to take a swing at it. Or is that the all-time low?

[BeHealthi]

Our private ins denied PSMA Pet as my husbands PSA is under 0.2. Husband will be on Medicare next year and he was told Medicare will covering it regardless of PSA. Is this correct? Which companies, Blue Cross or AARP United Healthcare, is better to get when dealing with PC?

[DrawingSnowmen in reply to BeHealthi]

This is true as long as you sign up for Traditional Medicare (not Medicare Advantage).

[BeHealthi in reply to DrawingSnowmen]

Thanks

[Don_1213 in reply to DrawingSnowmen]

I'll emphasize what DrawingSnowmen said - avoid Medicare Advantage plans - they're for people who think they'll never get sick. Get plain old Medicare and a Plan-G supplement and you're ready to go. Be careful of things from AARP - they're really acting as an insurance agent - meaning they get a commission - and they may not be working in your best interests (Medicare Advantage plans pay a big commission, which they pay to the agent annually as long as you keep renewing.)

Right now - since your husband hasn't had Medicare or the supplement - the supplement plans are forced to accept him even though he does have PCa. They ALL have to offer the same coverage (law) - so do a bit of price shopping. Medicare.gov should be in your bookmarks - it's a very useful website in determining what to get.

There is an initial annual deductible with plan-G, once that's met I haven't paid a cent out of pocket for medical care (doctors, tests, hospitals, treatments, etc...) and everyplace takes Medicare.

Drug plans are a different story... I won't go into it here, but I will comment that anyone who simply renews the plan they have without research on medicare.gov is doing themselves a disservice.

[BeHealthi in reply to Don_1213]

Thanks. We are planning to go with the original Medicare and for Part G, we have looked at AARP United Healthcare and Blue Cross. Prices are about the same for both, may be a little less with Blue Cross. I would like to ask if others can share with me about their personal experiences with these two companies for claims/PC treatments. Don, I would love to hear your personal opinions on Drug Plans as I also need to decided if I should have one. Please PM me if you would rather not saying anything here. Thanks for helping.

[85236442968 in reply to BeHealthi]

BeHealthi

Also Joeguy

Joe Guy you do not have your age in your Bio, so I will assume you are Medicare eligible.

After doing a lot of research, My wife and I opted for the Supplement Plan G, in 2022

The in 2023 a wonderful diagnosis of PCA including Lymph nodes.

Other than the deductible of $240, everything else was covered. Whatever procedures like MRIs, Biopsies, PET scans etc were covered no questions asked and no approvals.

Then at a family gathering (I have 5 siblings), we discovered we all had Plan G AARP United HealthCare Supplements, and we had never discussed it with each other prior to that day.

I do think shopping for a Plan G supplement provider is prudent as Humana, AARP-UHC, and a lot of others offer them. The coverage is defined and is standard.

Most drug plans do a good job on the std meds we all take. We have Well Care Value script. They do not help much with Abiraterone and such. the Cancer Center hooked me up with a third party non-profit that takes care of the Abiraterone co-pay.

In closing Research, research, then do some more research.

Best wishes on your journey

[dhccpa in reply to 85236442968]

Abiraterone isn't relatively cheap under your Wellcare plan?

[85236442968 in reply to dhccpa]

dhccpa

Well Care lists Abiraterone as a Tier 5 drug. That means they do not help much if at all with it. When I first started with it, they wanted around $1800 for the co pay. Good RX was in the $180 range so I leveraged the Specality Pharmacy to get a cash price of $182. I had to pay it for a couple of months then they got me hooked up with a Charatible Foundation.

The one that helps me is "The Assistance Fund".

Unless you have crazy high income, there are a number of associations, and non profits that help cancer patients with co-pays. Your Cancer Center Specialty Pharmacy can help with getting you hooked up with one.

To learn about them, use your browser AI assistant and ask the question, "What Associations, Foundations, Charitable Organizations or Non Profit Organizations can help me with Cancer drug co payments?"

Best wishes on your Journey

[dhccpa in reply to 85236442968]

Thanks. I thought my Wellcate plan was about $100 per month, but maybe I'd better re-check it. I've never taken abi but it might be next, so I try to keep an eye on it.

[85236442968 in reply to dhccpa]

Dhccpa

Best wishes on the Radiation.

I had 28 rounds of IMRT on Pelvic areas for both prostate and Lymph nodes, then 3 rounds of SBRT on Lymph nodes at Periaortic level. That was a year ago and so far so good.

Also Lupron and Abiraterone/prednisone. Been on this over a year and probably have at least about another year left.

A couple annoying minor side effects while doing radiation, mostly concerned with bladder and peeing. A lot.

About 6 months after radiation I started getting severe bowel cramps, and was a bit explosive. Ended up with a daily ration of yogurt to keep gut bacteria healthy and all is well. I honestly think with the pelvic radiation and mid abdomen radiation, they basically killed my intestine bacteria and it had to be rebuilt. MO says that he is not sure about that, but it obviously worked so maybe.

Best wishes on your journey and remember to be nice to the Radiation techs.

[dhccpa in reply to 85236442968]

Thanks. I'm on high alert for side effects, but it's very early. Maybe I'll get lucky, but peeing is always an issue one way or another.

[Dadyrabbit in reply to BeHealthi]

So after I was diagnosed with PC and after three biopsies over time I finally had a biopsy that showed Gleason 4+3 and urologist recommended either surgery or consult with oncologist. I asked about getting a PSMA scan and he ordered it. I have traditional Medicare and a supplement with AARP United Healthcare. I just checked my claim and here is what was charged and what was paid. This is only the charge for the PSMA scan...there was a separate charge for Radiology Interpretation.

Amount Charged $15,370.00

Medicare Approved Amount $7,705.92

Medicare Paid $6,164.74

Plan Cost-Share $0.00

AARP Plan Paid $1,541.18

So basically I paid nothing out of pocket (I had already met deductibles for the year)

I had no problems of any kind with them paying for the PSMA scan. It was not even questioned.

As a side note I also requested a decipher test on my last biopsy sample and have not received any information regarding payment on that but it is my understanding is that Medicare will pay for that....will have to wait and see if United Healthcare pays anything for that. Also when I met with Oncologist at Sarah Cannon (Nashville TN) he indicated that there was a study regarding the effectiveness of Decipher test and the study would pay for it. In hindsight I probably should have enrolled in the study then there would be no question. You might want to check with your Oncologist and see if you are a candidate to enroll in any study.

[gsun in reply to Dadyrabbit]

no wonder ins companies don’t want to pay for the scans. That charge is ridiculous. I can get a private scan for about $3500. That’s in Canadian dollars.

If Pluvicto didn’t work, maybe the FDG scan is the way to go. You had a PSMA scan after treatment so you already know what is going on. You probably don’t need a PSMA scan again. Probably a CT would be fine. JMHO.

[dhccpa in reply to BeHealthi]

I'm in Florida and have a UHC supplement along with regular Medicare. If Medicare pays its 80%, UHC pays its 20%.

[BeHealthi in reply to dhccpa]

Does your premiums go up every year? Medicare.gov stated that AARP United Healthcare premiums don’t go up annually but with Blue Cross the offering is low at the beginning but will be increased later.

[dhccpa in reply to BeHealthi]

I got on in 2021. I believe they have increased a little every year, but not too much. Right now they're $398 a month.

[hfl20 in reply to BeHealthi]

You may want to check with an insurance broker for your Plan G (and don't listen to any suggestions of an Advantage Plan). The Medicare.gov site will list all offered in your area, but the pricing is not accurate and most do not provide pricing on their website. The coverage is standard and the same regardless of the providing company but some are more financially stable than others. In most states, once you select a company you are stuck with with it forever (at least those of us with cancer) since underwriters can pick and chose who they will accept after your first year if you apply to change. In a few states you will have the option every year to select another Plan G or lessor from another provider. This recently happened in Oklahoma and I will be able to forgo my Mutual of Omaha plan G that has just risen to $290/month for one by Ace (Chubb) for almost exactly half that amount. I have used the Wellcare drug plan for years without problem and it is offered for $0 /month this year. Generic drugs have all been at no cost for me, and they covered exactly what Plan D is required to pay for the cancer drugs. The cap of $2000 out of pocket for 2025 also mitigates the problem with some of these pricey PC meds. You definitely want to have a drug plan. My copays alone have already topped the $8000 cap for this year. Orgovyx is over $4k per month and Erleada is over $27k/month. I was able to get some help with grants for copays.

[Retireddoc in reply to Don_1213]

I will offer a third agreement on getting Traditional Medicare and then a supplemental policy.

When you go to Medicare.gov to sign up for Medicare, You need to sign up for Part D which covers prescription drugs. For 2025 there is a $2,000 cap on out of pocket cost of prescription dugs.

I agree that people (especially those enrolling on Medicare for the first time need to go to Medicare.gov and read.

[raisin123 in reply to BeHealthi]

Under .2 it is pointless so I don't see why any insurance company would pay for it. Your cancer isn't officially back until .2 and even a PSMA would have trouble picking up cancer at that low of a PSA.

[raisin123]

I have BCBS and they approved mine with no issues. I was just getting radiation treatment.

[joeguy in reply to raisin123]

Yes, I’m pretty sure if you are planning to have radiation they will always approve

[BeHealthi in reply to joeguy]

That’s not true. We plan for radiations as well but insurance still denied.

[Explorer08]

I’m on United Healthcare Medicare Advantage PPO (not through AARP, however). No copays for anything except hospital admission. They readily covered my PSMA PET scan. I’m only on Orgovyx. Pluvicto is not required.

[TJGuy]

What state is your BCBS insurance in, what hospital is the denial be made too. Do you have Medicare advantage plan?So this is not true at all. Write back and I'll tell you everything you need to know to get the PSMA scan. I've had three this year last one was just Thursday.

[dhccpa]

I'm no longer on Blue Cross. Now on Medicare, which paid for my PSMA in July based on no future treatment. I had been on Lupron for six years and had five previous PET scans of different types. I guess Medicare is more lenient, although Blue Cross paid for many scans, including three PETs.

[CancerConcierge]

My husband and I are on AARP United Healthcare supplement.

He has had many biopsies, two PSMA PET scans, MRI’s and radiation with no copays/bills.

He is being treated at Mayo in Phoenix… Mayo will not take Medicare Advantage plans.

We will never change insurance plans.

[chefjlu]

Just went through a similar, although my journey is not the same as you. Original diagnosis Gleason 9, opted for RP and surgical pathology was T3aPN1. 3 years no treatment as PSA was undetectable - then slight pop in PSA and had a PSMA PET Scan and 1 spot found in the pelvic area, with a second very small spot in pelvic area undetermined. Started ADT - had 2 months of Salvage Radiation, PSA undetectable - ended 2 years on ADT in late May of this year. After 6 months my Oncologist wanted to have another PSMA PET Scan to check as well as have a baseline scan. The insurance (BC/BS Medicare Advantage) said no, but suggested an MRI. In consult with second doctor we discussed CT Scan & Bone Scan. So we opted for that course. Still a denial and my doctor sent an appeal (argument became a PSA undetectable) and interestingly they called me to discuss from the appeals board. I have extensive medical training and the conversation was not pleasant. I was quick to point out that High Risk (Gleason 8, 9, 10) can spread & grown without expressing PSA. I went on with other points and was told I would find out in 72 hours their decision. WELL, 2 hours later I receive a call and the CT Scan & Full Bone Scan were approved and another member said the Doctor I spoke with directly did not want to have another discussion with me such as this. I knew more about things than he did, and was 100% aware of my own individual risks and needs. ---- PSMA PET Scans usually are reserved for specific cause, Initial diagnosis - Rise in PSA - an MRI or CT Scan that indicates problems - they are very expensive and that causes the denial. Fortunately for me the Scans were clean except for a Sclerotic Lesion on One Rib (will require some watching) but no signs of metastasis. The bit of pain in my leg was shown to be arthropathy. ---- My point to much of this is BE YOUR OWN BEST ADVOCATE! Read, Learn, and Stay Connected. My 6 1/2 year journey has not stopped my life, and I do what I can for others I have met. Don't take "no" for an answer without explanation. Be ready to argue and present your case. I'm 65 and watched a friend from High School younger than me die last October from PC by accepting things he was told and failed to dig deeper.

[Hawaiirainbows]

wow, lots of different answers on this subject! I have Traditional Medicare, with United Healthcare as my supplement. After initial diagnosis of Stage 4, with Ct & bone scan, to confirm one small spot on my femur, PMSA scan confirmed it and no charge to me. A year later my Oncologist ordered another CT & Bone scan to see how I’m doing on Hormone Therapy and Xtandi. All good, still PSA not detectable . I asked him when he ordered the scans, with the PMSA being so much better in detecting even small cancerous cells, why not just order me a PMSA scan? He said we get that question a lot ! Answer was PMSA is much more expensive than CT or Bone scans, thus unless my PSA increases, Medicare will not approve it. Sounds like that’s not the case in some of your situations.