Insurance debacles

Health insurance, as good as it is to have, really frightens me sometimes. My dad's March PET scan was denied by the insurance company. His doctor had to have a peer-to-peer discussion with them, to see if he could get it approved. Well, he was able to. Thank God. I can't understand why an insurance company would deny this test? My dad's lung cancer isn't operable, (at least last we knew)... So why wouldn't they approve the CT, to make sure there has been no negative changes, or mets?

Sorry, just a quick vent. Frightens me that someone or someONES, can have this power over peoples' health and treatments.

5 Replies

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  • Was it a CT or PET? CTs are a lot easier to get approved, and PETs are not as commonly used for monitoring. PETs are much more expensive than CTs and not necessarily a more effective test. Insurance companies do not have an unlimited amount of money to use to pay for our tests and procedures, and they are trying to make sure that expensive tests are necessary. It's still frustrating when insurance companies second guess doctors' decisions.

    Anita

  • PET scans and CT scans are different. A CT scan will show that there is an abnormality, but only that it is a tumor or mass. A PET scan shows that the abnormailty is most likely cancer because it lights up the cancerous areas. A PET scan is much more expensive than a CT, so insurance companies regularly deny them, some simply as a part of their normal business procedure. You would be surprised by the number of people who simply accept the denial and pay out of pocket.

    I've been on this cancer journey for 15 years now, and have learned which insurance to choose to maximize the coverage I need. Perhaps you can talk to the social worker at the facility and do the same. It is astonishing how just changing insurance companies can open doors! I am on Medicare now, and going straight Medicare instead of using a Medicare Advantage company makes a huge difference in overall out of pocket expenses.

    Also, you might want to look into Medicaid to help cover the enormous costs. The hospital's social worker can help you navigate all avenues of financial assistance.

    Good luck in finding help - it is out there, but not easy to find.

  • My PET that was ordered for staging purposes after my initial diagnosis was denied. My doctor and teaching hospital said they had never had a PET for staging denied.

    My doctor had 2 peer to peer and still denied. I appealed and another conference was scheduled with me, them and staff on my Dr's team. 24 hours before the insurance company called to drop the denial and we went forward with the PET one year after it was ordered.

    Moral of the story as you may already know, we have to fight cancer and insurance companies too. We have to navigate the insurance system like a fine tuned machine with roadblocks all along the way. I'm self insured and not on Medicare. I understand Medicare will make this struggle a whole lot easier when the time comes.

    Side note, I changed insurance companies this year because they cancelled me after 8 years. I'm on Obamacare which will save me thousands! I'm grateful for it and hope we can improve it and make it last for everyone.

  • Best wishes to you and all. I was surprised when I was told that you needed prior approval for a biopsy from the insurance company. They usually give it but it does kinda burn you. I talked to my insurance company about pre approval for a PET and was told that because of the expense, they want to make sure it is needed and that this isn't a scam. Some clinics will game the insurance companies. That I know is true...but. I asked him if he had ever had a PET scan. He said no and I told him that I had and wouldn't do it if I didn't have to. I was blessed that when I was going through my treatments and so sick; my husband would do the insurance and I could concentrate on getting better. If you get denied, they should resubmit. Sometimes the coding will be wrong or it's the 6th Monday of the month.

  • You can always appeal and can often win, insurance is very fussy, but every time I have had to appeal a test, it was later coverage. However, for me, if the scan is routine for a follow up they will only cover a CT Scan, (not a Pet Scan) and as my Onc told me, they are less expensive and also use less Radiation, so it's probably safer too.

    I have them (CT Scans) pretty much done very 90 days, but have only had ONE Pet Scan and that when when I was originally diagnosed. My Onc told me, this is the standard of care. I'm also Stage IV, not sure if that make any difference.

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