Anyone Been told Medicare has a lifetime limit of 2?

SusanR

I am having trouble getting a PET Scan done as the Hospital I have been having them done at says I have maxed out my 2 per lifetime!! I cant get a straight answer from anyone, and just recently found out that Medicare hasn't paid for my last 10 Scans and the Hospital has absorbed the cost of those but won't let me have anymore!
My physicians Office is not helping much, even though I believe the issue is their lack of correct coding to support medical necessity.

Are there any Medicare afficienados on here with any ideas?

BevJen

Susan,

If you will google medicare & pet scans, you should find some info. From what I can see (and this was discussed on another thread) Medicare will provide a lifetime limit of 3 PET scans for the same "condition." I have no real idea what that means, or if docs/hospitals can do something to get these things covered. On the other thread where this was discussed a few months ago, some folks were saying that they have had multiple PET scans -- even folks who were on Medicare, supposedly.

I have lobular cancer, and I can tell you, they don't have a flippin' idea what is going on with my bones because it shows up weirdly on CT scans and also on nuclear bone scans. Because I also have liver mets, and my interventional radiologist does MRIs for that, I've gotten some sense at least of the middle of my back (it's an abdominal MRI). This is a real problem, though.

Good luck on this.

Moissy

Susan - I’m sorry you have hit a wall on the scans. So frustrating trying to get at the root of the problem, I’m sure. I’m definitely no Medicare expert, but I can confirm that I get PET scans every 3-4 months and Medicare pays for them. So I believe that you’re right that it has something to do with how the doctor’s office is coding their request. I’ve seen that “limit” idea posted elsewhere on the boards by others who have also been declined. But I have never experienced a refusal by Medicare for a PET scan. Is there a patient navigator position at the hospital that may be able to assist?

Micmel

yes, I've been told the same thing. My onc suggested coding for dexascan . Bone density test but can see bone involvement also. That’s how we got around it. But it is limited, I was told that as well at diagnosis.

JCSLibrarian

I was told by my Oncologist’s office that Medicare has a limit of one PET scan for diagnostic purposes, then 3 over three years if there is no cancer progression. I blew through that in the first year with scans every three months. I am now scheduled for a nuclear bone scan and CT scan until things change. If there is a ‘trick’ to the coding, I am sure most oncologist’s office would know about it and use it. I do wonder if having two tests actually costs Medicare more or not. They assure me that these two tests, while a hassle for me, will show what needs to be seen for our purposes.