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.
trouble with insurance denial of PSMA... - Advanced Prostate...
trouble with insurance denial of PSMA scan
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joeguy
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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
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.
Yes I had that same CT and bone scan requirements before I could get my PET scan. Seemed wasteful to require these scans again.
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?
This is true as long as you sign up for Traditional Medicare (not Medicare Advantage).
Thanks
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.
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.
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
Abiraterone isn't relatively cheap under your Wellcare plan?
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
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.
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.
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.
Very helpful info. Thank you. Although I don't currently take any cancer meds if/when I have to start it is good to know there are some potential sources for help. I currently take Farxiga for heart disease and Dia eyes and Wellcare has it as a Tier 6 drug in 2024. For 2025 they are making it Tier 3 which will make my Co pay a % of the cost ultimately making my quarterly payment even higher than this year.Not a big fan of my Wellcare Rx policy and their approach may also be applied to various cancer meds.
Another resource for Abiraterone, if there are out of pocket expenses, is Mark Cuban Cost Plus Drugs which is an online pharmacy that sells drugs at wholesale (plus $5 per scrip). Just checked Abiraterone and for a 30 day supply the cost is $26.90.
Goletasurfer
Hey, thanks for the response.
Yes, Cost Plus is for sure in my toolbox.
I have not used it yet but certainly will when needed.
Im 61 with employer provided blue cross insurance
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.
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.
Before the Australian Government started paying for a PSMA PET scan I had to pay AU$700 (about US$500). I paid for 2 scans and have had a further 4 at no charge. I wonder why they are so much less expensive here in Australia.
Australia is at the forefront of PSMA scanning and radioligland treatment.
I'm in Florida and have a UHC supplement along with regular Medicare. If Medicare pays its 80%, UHC pays its 20%.
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.
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.
I don't know if AARP United Healthcare goes up every year or not but I do know they increased this year over last year. I don't recall exactly how much...but this year my AARP United Healthcare Supplemental premium is $417.63 Per month. But everyone is different due to health situation. I am just shy of 73 years old and have had heart attack and quadruple bypass in the past. That probably puts me in a riskier group than people younger with no major health risk in the past. I also got my supplemental policy several years before I was ever diagnosed with PC.
Wowed, $417.63 a month. I assumed that you started with the same company at 65 and the premiums were a lot lower. If so, the insurance has increased your premiums for a lot since then because of your health risks. I assume the insurance would do the same with PC treatments.
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.
You definitely need Part D to go along with Traditional Medicare. If you go to medicare.gov and enter all the meds he's taking it will help you select a plan. One thing to keep in mind is that some of the PC drugs must come from a specialty pharmacy, not CVS or Publix. So find a specialty pharmacy (maybe ask the oncologist for a recommendation) and choose it as one of your pharmacies at medicare.gov to be sure the plan you select has them on the plan. They are not allowed to exclude *all* specialty pharmacies but some try do it anyway. They can save a ton of money if you can't easily get something like Erleada for example. So even if a specialty drug hasn't been prescribed it might be down the road, and you'll need a specialty pharmacy for that.
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.
I will add that in my area there are quite a few physician practices and even some clinics and hospitals that no longer accept Medicare Advantage plans.
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.
Stay AWAY from advantage Medicare, Don't do it!!!Get traditional Medicare, your care depends on it.
I was at MAYO last week, I already knew and have been telling people advantage Medicare is the WORST mistake you can make. But I mentioned I'll be going on Medicare in 2025 and my Dr said the same, that Mayo wouldn't likely continue to accept me as a patient if I got advantage Medicare.
I have BCBS and they approved mine with no issues. I was just getting radiation treatment.
Yes, I’m pretty sure if you are planning to have radiation they will always approve
That’s not true. We plan for radiations as well but insurance still denied.
I would fight that or at least make sure the doctors were fighting for you by providing their reason for ordering it. Medicare and my AARP paid for my PSMA even though I have not started treatment yet. I had requested the scan because I have a lot of pain in both shoulders, hips and back....probably just arthritis and/or small injuries but since I had not yet decided on surgery or radiation I asked for the scan to make sure nothing had metastisized yet as it could affect my decision on treatment methodologies.
Thanks. The RO did the peers to peers review but our insurance still denied. They offered MRI with/without contrast and it’s negative.
will probably have to wait till PSA starts rising again to justify the scan…. It’s fairly stable at 17 right now
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.
Don't ever get on an advantage Medicare plan period.
I certainly understand your reticence, TJ, but our Advantage plan has been spectacular. We've been in it for two years and will be again next year. My wife and I both have very complicated health issues and everything is covered without copays, including medication.
One has to be very, very cautious when selecting plans and a LOT of homework must be done. I do not expect our plan to last forever, however....I don't know how they do it given the bad reputation of most Advantage plans.
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.
I have blue cross blue shield of Oklahoma . Not old enough for medicare
So I have received denials from BCBS NC on a number of occasions. Even before all the BCBS companies outsourced their decision making to other companies for these denials.
My very first PSMA was denied because my doctor at Mayo doesn't do peer reviews. On that occasion I trusted that they would get the approval after the PET scan. The financial worry on my part was awful, they did get the approval on appeal months after my scan, but I've never done that again.
So I was denied on my PSA being less than 1.0 I personally appealed with a well written multi page letter that highlighted that 8 to 10 percent of Prostate cancers do not produce PSA. And that my doctor was seeking to determine if I has such a cancer, I was approved for the scan. I had been on Lupron for two years after whole pelvic and pelvic bed radiation to five spots in the pelvis and was coming off Lupron. While on Lupron my PSA hit a low of <0.01
I've been off all meds since July 2021.
I had a approved scan in fall 2023, which detected a positive lymph node in my pelvic right side. I had SBRT at Mayo for that. I was to have a PSMA scan in February 2024 but was denied because no peer review. I was in Florida, so I immediately scheduled a appointment with Moffit hospital in Tampa. I told them my issue and they said they do peer reviews and have no problem having them approved and work with snowbird patients and their northern hospitals I was approved at Moffit and had one performed there.
I sent the results to Mayo this time directly to my radiation doctor, who does perform peer reviews and doesn't have issues with approval. Mayo prescribed another PSMA on their machines which was approved. So two PSMAs scans in 3 months (don't back down, be assertive). By the way three months is the minimum time period between scans. I then had SBRT to the left lymph node in August 2024 which was not detectable in 2023 but predicted by Mayo software.
I just went back last week (three months later) for a approved PSMA to look at both lymph nodes this from my regular urologist at Mayo. My PSA has been dropping and is 0.6 PSMA shows decreasing cancer (SUV) in each lymph node each time. No new cancer occurrence found.
I will monitor PSA every one to two months and if see any increase, I will get a new PSMA scan in three to four months.
I have had regular PSA tests during all this and my PSA was increasing before November 2023 radiation, then dropped for three months to 0.5 before slowly increasing, but it was still around 0.8 when I had the PSMA scan before the second lymph node was radiated. My PSA is still dropping currently 0.6
So make sure you have access to a doctor that does peer reviews. Have multiple hospitals and doctors to go to.
Back when I was getting Lupron shots at another cancer specialty hospital in Florida they mentioned to me they have had only a few patients get approved for PSMA scans. So they are in a region of Fl where many of their patients are on HMOs and on advantage Medicare,
So never get on Advantage Medicare (for many reasons). So don't waste your time getting approvals with hospitals that don't routinely get approvals. Same for doctors. Always have workarounds to get around denials.
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.
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.
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.
You have to be your own advocate and become knowledgeable. No one will fight as hard for you and you will for yourself. Like you I am more familiar with the medical field (having worked in the field of Radiology for over 20 year) so the terminology is familiar for the most part, I also am not intimidated by the presence of doctors, etc...I respect them but am not afraid to ask questions. Reminds me of a story from my early years as an X-ray tech when we had an elderly come in for x-rays for her gallbladder. Patients would take several pills of a substance that would be picked up and stored in the gallbladder to make it visible on the x-rays. We would take an initial scout film to see if the gallbladder was visualized before we took other films. This particular patient we did not see the gallbladder so we asked her if she took the all the pills and when she took them since we did not see her gallbladder on the scout film. She replied..."yes I took all the pills but I am not sure why I had to take them since I had my gallbladder removed several years ago"....we asked .... well did you tell the doctor that you had your gallbladder removed and she responded "oh no dear...doctors don't like it when you ask too many questions!!"....I almost started laughing but a lot of people feel that way.
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.
Well joeguy you asked and you received.
Good Luck, Good Health and Good Humor.
j-o-h-n
Bruce W here, I had a PCMA/PET in 2020 and the new version was not yet approved. I was entered in a program at UCLA and paid for the procedure. Don't remember exactly how much, but given what the test could, and did revile, and that I was diagnosing Prostate cancer the cost was secondary to the likely help it could give. I have had ADT for 3 1/2 years, stopped in July 25, 2024, so far tests are all OK. Getting retested every 3 months. Best of luck with your quest. Bruce W
Unless your insurance contract specifically states psma scans are only covered if you're getting Pluvicto (and trust me it doesn't), the test must be covered as long as treatment is
a) medically necessary and
b) within AMA guidelines. Example of a legitimate denial: If your PSA is under .2, you don't meet the guidelines as defined by the AMA.
Your Oncologist will appeal on your behalf.
Have your doctor advocate for you with insurance. They often have a pre-written letter they can send on your behalf explaining the need for the PSMA PET. My husband's cancer does not product PSA so he HAS to have PSMA PET scans because his cancer only emits PSMA. It's the only way to see what his cancer is doing and where it is.
But we had to have his doctors advocate and explain why it was needed, and then it was covered.
Typically, if your cancer produces PSA they won't cover it because they'll say the PSA blood test is how you monitor prostate cancer. There can always be exceptions and your doctor can advocate for you.
Often, you should try to get pre-authorization. That will avoid the whole after-the-fact fight.
joeguy unless I missed it, it would be nice if you closed this thread out. What was the outcome please? Was it paid?
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