Insurance not approving PET Scan

I just finished chemo in Jan. 2012. PCI in Feb. Onc ordered a Pet scan and insurance said it was not medically necessary but investigational, therefore it was denied. I have had 1 pet scan at diagnoses 9/11/11. I ct scan in Dec. 2011. What are your doctors doing to get approved? My insurance is not through work but I pay. BCBS. How does the insurance co think you can treat something you can't see. Talk about stress. I have no idea if my cancer has gotten better or worse since the ct scan in 2011. I guess they just hope you progress and die. I have Limited sclc. I pray it is still Limited.

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If it is Blue Cross you will have to call them and fight, the doctor will have to write a letter and fax it, as well as mail it. They do not make things easy with most insurance companies. If you can pay for the scan yourself you can negotiate the cost of it with the hospital and things will move along at a faster pace. PET scans are a bit expensive, but most hospitals will work with you on the cost might be able to get it under one thousand dollars.

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I have BCBS, and they're definitely cracking down on PET scans. A CT with contrast will tell you whether the tumors have increased or decreased in size, which is the main thing you need to know. Try not to worry.

MJ

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Why would you want ab expebnsive PET scab that provides less information to the doctors than a CT scan?

The CT scan reveals if there is a tumor (cancer) and if it has grown since the last scan.

The PET scan is a far more limited and imprecise test. All that it reveals is if an organ is "hot," namely is showing growth. If you have had an infection, sergery an accident, it will show up "Hot," on the PET, giving a totally incorrect reading!

Hospitsls like to recommend PET scans because they can charge you far more than giving the more inofmrative CT scan. Because the PET gives off so many false indications, the hospital can use it to order still more tests (to increase their income!)

It's purely a scam in many cases,, although it can, (1) with other tests, and (2) under certain circumstance be of assistance in diangoising condtions.

HighlandGuy

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Cathy, don't stress; can your doc get approval for CT Scan? My understanding from my oncologist is that the CT is more precise and informative than the PET-- the CT gives more specific info that just showing hot spots.
If you and the doc are bent on having PET -- get your fight mode on and go at it with BCBS.
Wishing you only the best

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The same happened with me and my Ins. Aetna. I had one Pet after diagnosis and then Dr. wanted another after treatment but my ins. said no. My oncologist did everything and even had a phone conversation with a Dr. working for Aetna and both agreed stupid, but Aetna policy. My Dr. said what is being said about CT scans are more precise and said we will save the battle for another time if he feels needed. I have had CTs, MRIs, bone scans for 5 years with initial diagnosis of Ext. SCLC. It does make me mad that our Ins. Companies have so much power over our medical care.

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My BCBS is an HMO, and for CT's, they don't even need to pre-certify it when my oncologist orders it. They're getting really strict about the stuff that does need to be pre-certified though. I got a notice from BCBS that if a test gets done before it's pre-certified, the patient can be charged as much as $500 even if they certify it after the fact.

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I had one pet early on when I was first Diagnosed.
Now I alternate every 3 months, cat scan, chest x rays.

MARIA

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Did you say you had a PET last September. It is my understanding just once every two years with CT's in between is sufficient. Am I wrong?

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A PET is not protocol for following LC unless there is a problem. If you have a CT or bloodwork that's off for an unknown reason, then a PET would be approved. My doctor ordered one after my 3rd chemo and before my 4th as my bloodwork was off. He felt it could've been progression in the liver. It was at first denied and he personally got on the phone with my insurance. Then it was approved. They are more expensive and not medically necessary.
Take care, Judy

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This is BS...seriously, it is one example of the reason for the demise of healthcare in this country and why we are in crisis with Obamacare!!! The insurance companies have taken over where big Pharma was and now they are BOTH in control. Professionally, I've watched this nightmare unfold over the last 30 years...prior authorization was NEVER intended to be the physician!!! Please don't get me started on "clinical guidelines" (that are used by the auth reviewers to justify denials but development of such are funded by both pharma and ins) lol...Sorry, I'll get off of my soap box....

What you are asking for is REASONABLE but would be more clinically justifiable if further out from the CT scan (eg. 3 mo. or in addition to sx's or 6 mo-1 yr from last PET...the water is kind of muddy right now w/ the recent changes in guidelines).

I just went thru this myself in March...it took me THIRTY DAYS to get it done. I was so stressed out and depressed over it and it RUINED that month for me. At the end of the day I realized I kind of put myself in a tizzy...only to realize the results confused the situation/me even more! So please keep it in perspective.

There are differences between CT and PET scans. In my opinion, the CT provides the anatomical data and the PET shows the activity. I participated in a clinical trial specifically for PET CT Scans with cancer tx and had one on day one of another clinical trial that included Tarceva and Fasalodex, on day 1, day 14 and 3 months. Consequently I ended my clinical trial and stopped the Fasalodex (that made me miserable) and continued on the Tarceva. I was GRATEFUL to have the data to make an informed decision. My quality of life increased 100% as a result of my decision and I have enjoyed myself at the gym working out regularly ever since :) The CT does show enough for the Drs to do their routine assessments. The PET can be VERY sensitive (eg. NO exercise 24 hrs before as it increases uptake) but if done right, can provide useful info..

You have rights...if you perceive you need it, you are in control and have the option to fight for it. There is always the option of submitting an appeal. However, it might be easier (and less stressful and more successful) to submit another request when you are further out from your last CT (so its 3 mo. after) and if its denied, appeal then. Each state has regulatory controls over the ins co/payers and contacts available to assist you with complaints (your healthplan can also give you that info).

Good luck...bear in mind the saying, "treat the patient, not the diagnostic test/scan/equipment!!!" Let me encourage you to stay positive and in faith as God is the best physcian/healer of all :)

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The train on managed care control over healthcare has been on a roll for a long time, well before the Affordable Care Act. My husband worked for a major healthcare company back in 1999 and even then they contracted out to a company to do their radiation authorizations with a wink and a nod to make it easier to deny the authorization. At least the Affordable Care Act prevents insurers from dropping us because of our condition.

But, enough politics. Your oncologist has to go to bat for you. I find that a good oncologist is well versed on how to go about fighting for and getting these insurance companies to ok the scan. It just takes a little time and things may not happen as quickly as you would like them to. Invariably, the request goes into medical review and requires a peer to peer conversation. I find that the conversation consists of the doctor cherry picking just about the worst possible information to help them make their case.

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Politicizing with "Obamacare" my foot!!! If it was left up to McCain and Palin I would have been dead with my cancer.

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My Onc only orders for me Pet/Ct scans combo and I wouldn't it any other way. Pet and Ct both can give off false positives. Had ovarian mets to the peritoneal (abdomen lining) missed by Ct scan. Only found when I had surgery to removed what we thought was cyst, and that was a shocker!

It's the Onc preference on how to follow up and if he or she is going to get on the phone etc to get Pet scans approved.

My Onc has also told me that he has had to get on the phone and argue with the insurance company to my scans approved.

Pet scan is a very useful test in diagnosis, evaluating treatments, surveillance and follow up.

My insurance(s) covers the scan and im worth every penny and will take any assistance I can get to keep fighting to win against LC.

Francine

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Thanks for the education and encouragement. I am less stressed today even though I still have to have the CT scan. I guess I was upset that the onc asked for a PET and I assumed that was the best test to get. Now they are OK with the CT. I did read about the 2 and I believe the integrated PET/CT done together seems the best. That Is what I will try and go for next time. I am having Chest Abdomen, and pelvis with and w/o contrast. So Please say a little prayer that I am NED.

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Dear Woodsjran
Sorry if i didn't communicate clearly, I didn't mean to step on any toes (btw I AM a democrat and VOTED FOR Obama and was active in his election)...lesson learned: healthcare industry and government politics are too sensitive of topics to mix on this site :)

Dear Cathy24...Positive thoughts your way for NED!!!!

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Praying for NED all the way

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Well guys and gals I am having wine, chocolate cake,and red meat tonite!!!! And of course i have already danced.

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