Long story short.....
Diagnosed 3C Jan 08. Had Kaiser Colorado at that time. No problem getting a PET........had 3 in a 6 month period. Never even suggested that I get CT. CA 125 is not a valid monitor for me.
Quickly into remission after standard 6 Carbo/Taxol treatments.
Naive me.....never even considered that fighting an insurance company would be part of this picture.
Moved to CA. Not with Kaiser anymore. Now with BS (appropriate initals, huh?). Due to inability to use CA 125 for monitoring, the Onc ordered a PET, and even though CMS now is on board which should lead the way for insurance companies to follow suit, I can't get one. CT only. CT shows enlarged lymph nodes and doc wants to know more in order to make tx recommendations. But apparently we will have to battle the insurance company to get the PET.
Does anyone have any experience or advice in fighting insurance company for what you need?
thanks
Jeanie
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Anybody have experience fighting for a PET?
- By jeaniet
- Posted May 7, 2009 at 10:22 pm · 10 replies
- In Financial and insurance issues
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10 replies
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- By AlexM06
- Posted May 7, 2009 at 10:55 pm
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Jeanie,
I was denied a CT/PET scan not by my insurance company directly but instead by their third party approval agent Care Core National. The way I was able to get my CT/PET scan authorized was to download the “protocol” document from the Care Core National (CCN) website, reviewing the criteria that CCN uses to approve/deny the PET scan authorization; then gave the information to my oncologist in order to expedite the approval process. Getting the third party authorization agent, which is Care Core National in my case, to approve a PET scan usually would take me about one or two weeks worth of phone calls every day or two to ensure that the review was in process. I know it is very difficult and stressful to work through these challenges with your insurance provider. I found that persistence does payoff in the end. Good luck!
In Unity,
Alex
- By plk
- Posted May 8, 2009 at 3:06 am
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If you have a possible bowel blockage when they call the insurance company, they won't turn you down. Hope that helps.
- By DebRhena
- Posted May 8, 2009 at 11:15 am
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Ask your physician office to request a physician to physician consult with your insurance company. Every insurance company has a physician they use so if your MD will request a consult directly with the insurance MD they will usually approve. I never get approved with the nurse to nurse consult but each time they have done the MD to MD, they approve it every single time!
- By lovemnms
- Posted May 8, 2009 at 2:04 pm
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I have BC/BS they don't cover PETS. My doctor tried to get me one by speaking with the doctor from insurance company personally. He was firm with his no. They might consider one if my CA125 goes up and something shows on a CAT scan. Thanks a lot is all I have to say. Oh, they were nice enought to tell me I could pay for it myself for about $6,000!
- By mmtraynor
- Posted May 8, 2009 at 7:53 pm
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I was diagnosed in October 2005 with Primary Peritoneal, no tumors, just cancer cells in the Peritoneal. I am on Medicare and Medicare would approve PET scans for many things, and many types of cancer, but not Ovarian. After many visits to the doctor's over seven months I finally got an email in memory of Gilda Radnor and self diagnosed myself.
Last year I went to a symposium put on by a
Dr. Rivkin who is an Oncologist in Seattle and one of the days during the lunch they had a one hour side seminar on the benefits of PET scans for Ovarian Cancer. We spoke to Dr. Rivkin and told him that my doctors in Spokane would not order me a PET scan, and he told me if he wouldn't then to contact him and he would get me one.
The next time I saw my doctor in Spokane I cancelled the CT scan before seeing him, and at the appointment I told him that if he couldn't get me a PET scan, then Dr. Rivkin in Seattle could. A week later I was getting a PET scan.
Dr. Rivkin's wife died of Ovarian cancer ten years ago. Since then Dr. Rivkin and his five daughters have devoted their lives to finding a cure. His organization raises money and gives it scientiest around the world to study the cure. There was even a doctor from my home city of Melbourne, Australia participating. He holds this Symposium every two years, and I definitely plan to go again next time.
My doctors will get me a CT scan any time they fancy, and I had an extra 12 months of chemo, but you have to fight to get a PET scan to see if you need the extra year of chemo.
- By Haynes94
- Posted May 11, 2009 at 4:15 pm
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Oh yeah! In fact, I made the front page of the paper for Blue Cross denying my PET scan! Check out the article here: http://www.news-record.com/node/9325
- By shoppingkharma
- Posted May 11, 2009 at 4:59 pm
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I hate to say this, but with this disease; it's important to enjoy every day that you can. Please try not to stress over this; I find the PET scans very discouraging and because of the solution they put inside you it make the cancer more active. If your cancer is advanced as mine is; it's hard to get rid of all of it. I had the second look surgery and we were to go on intra peritoneal chemo; the port was installed and during that surgery, my intestine was accidentally knicked. I got paritonitus which was a blessing. It knocked my CA125 down to 2 and it stayed low for 3 and half years.
I have had several PET scans and all of them were discouraging. That's just been my experience; you pee out radio active waste and of course over time the CT scans can also prove more harm than good. For now, I hope that you enjoy the low numbers for as long as you can. A cure is in the works and you must have hope. Try not to stress to much about it. I wish you all the best!
- By jeaniet
- Posted May 11, 2009 at 5:51 pm
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Unfortunately for me, CA 125 is not valid, so for monitoring I need either a CT or a PET. No choice if I want to keep living.
Jeanie
- By SouthernBelle
- Posted May 11, 2009 at 7:17 pm
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Jeanie,
CMS recently added ovarian cancer to their coverage for Medicare/Medicaid. See below
Previously, PET scans for many cancers would be reimbursed only if the PET facility submitted data to the NOPR. Now, all Medicare beneficiaries with certain cancers will be able to receive Medicare coverage for at least one PET scan, as prescribed by their physicians. The nine currently covered cancers— breast, cervix, colorectal, esophageal, head and neck, lymphoma, melanoma, non-small cell lung and thyroid—have all been expanded to cover the subsequent treatment strategy, in addition to initial diagnosis. Additionally, Medicare is now expanding coverage to include ovarian cancer and myeloma, making a total of eleven indications now covered for both the initial diagnosis and subsequent treatment strategy for patients. For all other cancers, PET coverage for subsequent treatment strategy evaluation requires participation in an approved Coverage with Evidence Development (CED) program, such as a modified NOPR.
Ask your physician to write a letter to your insurance and ask your facility if they participate in the NOPR registry. You can google CMS PET scan and read the new coverage. It is now recommended to have PET scans while receiving chemo to see if the therapy is working.
I hope this helps and good luck,
Mary
- By 1knocR
- Posted May 11, 2009 at 9:20 pm
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If it is still valid, PETs for recurrent OVCA is still experimental and that is why some insurances refuse to pay. I battled Aetna for 6 months only to find out that it was filed improperly. Once I reached an experienced insurance person, she refiled it under a code that was accepted. And we're talking $5,100 I was going to have to pay! Have you tried an MRI? These are becoming better at detecting recurrence along with a CT. I had both done.
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