Need help deciphering denial explanation

[kiteND]

As described in my bio, I consistently have nondetectable PSA but have mets that have appeared and grown during this time. They show on a C 11 or PSMA scan. In fact, I am receiving Pluvicto at the moment. I get the scans specifically because looking at PSA alone is not reliable for me.

My past insurer -- I've changed since -- has denied coverage for a scan done last September as medically unnecessary. I'm having trouble deciphering the insurance company's explanation. It looks to me like the reason is because I had undetectable PSA. The explanation is attached, except for the conclusion, which stated:

"The request for PET scan in this patient with known metastatic prostate cancer and no detectable PSA did not meet medical policy criteria. It is also not recommended by NCCN guidelines. Therefore, after a review of medical policy and clinical documentation this request is not considered medically necessary."

Am I right in my interpretation? I could use some help with this.

[chefjlu]

Yes, generally PET Scans are not approved if PSA is undetectable. I ended ADT last May (2024) and have been undetectable for over 2 1/2 years. My Gleason score was 9, meaning that in some cases the cancer can spread or grow and not express PSA. My oncologist wanted to have a PET Scan in November (2024) to get a full check and "benchline" so to speak. Denied as I told him it would be. Instead, the insurance suggested an MRI. I pushed back for a CT Abdominal Scan and Bone Scan. This would give a better look at any other possible issues (I also have a Mitral Prolapse/Regurgitation) I should attend to. They denied again, appealed filed and interestingly a doctor on the insurance review board called me directly. A 15-20 minute discussion ensued and I backed up everything and reasoning. Told it would take 72 hours to hear - however, about 1 hour later they called and told me it was approved. Comment was that the doctor didn't really want to have another discussion with me as I understood what I needed better than he did. ---- My point is to do the research and have the back up to explain the reason. Doctors know how to deal with this well, but as my own best advocate I am ready to put it on the table fully. My CT Scan did show a small amount of calcium on my coronary artery which my Cardiologist and I have addressed. It also showed a bit of arthropathy in my right leg and feet. Take the time to look beyond the PC and utilize every tool to check any other concerns.

[j-o-h-n in reply to chefjlu]

To chefjlu,

I guess your little doggie said to you "sic 'em boss" and you did......congratulations. That's one for the Gipper.

Good Luck, Good Health and Good Humor.

j-o-h-n

[NecessarilySo]

My understanding is that you have metastases, but they are not growing fast enough to express PSA, because ADT lowers testosterone but does not kill them, but they sit there without any notable growth. So the insurance company policy is that they don't pay for scans that are in their opinion, unnecessary, based on PSA readings. So they will pay for metastases that are growing but will not pay for nongrowing metastases. This would probably be okay as long as they do not grow, I mean, they are like benign cancer tumors. Worrisome.

[kiteND in reply to NecessarilySo]

That would make sense, but mine have grown and new ones have appeared. This has been typical for me for nearly three years. If had not been receiving regular scans, I and my docs would have never known that they were growing and more appearing.

[NecessarilySo in reply to kiteND]

Sneaky devils.

[Rocketman1960]

Not all PC express PSA. PSA is a great marker but doesnt detect them all.

[kiteND in reply to Rocketman1960]

Right! Which is why I thiink the scans should be considered "medically necessary."

[Wgly in reply to Rocketman1960]

Does insurance believe that no increase in PSA means you have been cured, or that all forms of PCa express PSA? How can they assume all that?

[kiteND in reply to Wgly]

Well, that appears to be what they are saying. However, the punctuation -- or lack of -- makes it confusing. And I'm a lawyer.

[Rocketman1960 in reply to Wgly]

I'm not an insurance expert. I have seen all kinds of assumptions with insurance companies that were wrong. Be your own Advocate. Hell the CDC recommended not even testing for PSA a decade ago. Wrong!

[Rocketman1960]

No argument from me.

[kiteND]

Update: The page I attached shows the criteria for covering a PSMA scan, but the scan at issue was a Choline-11. They could not even give me the correct denial.