PET scan and insurance

[Judy]

I was diagnosed with IDC last July. 3 cm, ER/PR-, her2 +3, fixed nodes at diagnosis (after surgery 9 of 16 nodes). Oncologist ordered a PET scan for staging as I hadn't has surgery yet and they were trying to find out if I was IIIA, or IV. Since that time the insurance has continued to ask for more information. I just received a letter today that they will not pay for the PET scan (although they did pay for the meds to do it!) as staging is not an approved use for PET scan. Anybody else out there have this problem? How did you appeal? Were you able to get the decision reversed? Any advice you have will help as right now it looks like we just have to come up with the $3800. BTW...it is BC/BS. The good news...one year later I had a clean exam:-) So far so good!

[Christine]

Would your onc feel comfortable with an MRI or Cat Scan?

Check to see if they are approved.

Hugs
Christine

[Janelle]

Judy,
This web site seems to serve as liaison between the patient and the insurance companies in times of dispute. Hope it helps.
Hugs

[Lolly]

Judy, I have BC/BS also, and they did pay for a PET scan for me a few months ago when we suspected I was having a 2nd recurrence of mets to lymph system; however I asked the nurse to get pre-authorization first as when I had my first recurrence in 2001 and asked for a PET scan to confirm NED after treatment, they denied it on the grounds that "...PET scans are considered investigational for diagnosis of breast cancer..."
So basically, they refused to cover the PET when I was asymptomatic but wanting to "fish around" to confirm NED, but agreed to cover it when I had symptoms I wanted to have confirmed without going through CT and Bone scans and maybe biopsy which would have totaled more in cost than the PET.
Hope this is hopeful,
Love, Lolly

[Judy]

Thank you all for your replies. I have gotten some good ideas here. For me the issue is that the PET scan was done a year ago when I was first diagnosed and they are just now refusing to pay for it. I see the oncologist on Wed. and hopefully he will help me get them to look at it again. It's like the cancer journey...one step at a time...don't look too far down the road....do your homework! I was more wondering if anyone else had had a PET scan that wasn't stage IV and if they got it paid for...and how. My rule with the ins. co. is...turn it in at least 3 times before you go too far. This one is on it's third time....but I'm still going for it! Thanks for the help....

[Leslie]

Hi Judy,
I had a PET scan about 8 months post diagnosis to evaluate an axillary lump. My insurance covered it. The lump turned out OK, but a couple of other things showed up. CT and MRI didn't document anything so I had a repeat PET 4 months later. The insurance covered this one as well. Not sure that this would be the case had I not had a particular thing that was being looked at. Good luck - it is hard to have to fight for coverage when our lives are at stake.
Love, Leslie

[Steph N]

Judy -
I did have a PET scan during my staging at the University of Washington. That was in Nov. of 2000. This was quite new at that time, but my med onc wanted to check on the extent of movement of the cancer prior to lumpectomy (if that was what was called for), also a a tool to check both breasts for other tumors since it had not shown up on the Mammogran due to dense breast tissue. So, it was used for limiting unnecessary surgery as well as finding out the other breast was clean, AND this is AFTER I had breast MRI's. With the very high grade type of cancer, and other problems, they managed to get my insurance to pay for it after they bounced the bill back and forth a couple of times.
The cost was NOT as high as yours - somewhere in the low $2,000 range which was scarey enough!

[Linda in Calif]

Hi Judy: Sorry you are having to deal with insurance issues. I just wanted to make one suggestion, if they don't approove the PET Scan you might go to whomever did it and explain to them that you have been left "holding the bag" so to speak. I have found that sometimes the Drs. will make significant adjustments in their charges if they know it is coming out of YOUR pocket. Take Care, Linda

[Judy]

Oh Steph...that is exactly what I wanted to hear! That would seem to be the exact situation I'm in...except for not having a previous MRI. Nice to know that you finally got it paid for after it bounced back and forth! You give me hope:-) I think I got caught in the middle when the PET scan center was just brand new and they didn't have all of the insurance procedures set up yet. I just hate to have to pay for someone's mistake. I can't complain too loudly though...they are paying for the herceptin at stage 3A without a question! So...compared to having to self pay for hercepting, paying for the PET looks like a bargain. Won't keep me from trying to get them to do it though. Thanks for the information!

[Lizzie]

I was told (by someone at my ins, I think)that if they didn't pay initially, that my dr should assign a different code, and then it should go thru. They made it sound like it would be paid. It's just a matter of finding a code they can live with. Good luck and God bless.