non approval PET scan

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tviolet
tviolet Member Posts: 2
edited June 2014 in Employment, Insurance, and Other Financial Issues

Hello, new to the board. My mother was diagnosed with stage iv breast cancer 5 months ago.  Her doctor scheduled her a PET scan this month to see if the medication she is on wa slowing progress and we just heard back her insurance denied coverage because of her stage iv diagnosis. Any advise on how we fight this?

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  • exbrnxgrl
    exbrnxgrl Member Posts: 12,424
    edited November 2012

    I don't have traditional insurance. (Kaiser HMO, never see a bill, covers everything) but I am sure there must be an appeals process. Your doctor could surely state the medical necessity for this. Many, if not most of us at stage IV do get PET scans at regular intervals. Good luck and don't give up.

    Caryn

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  • peggy_j
    peggy_j Member Posts: 1,700
    edited November 2012

    Sorry to hear this. Yes, most insurance companies have an appeal process and your mother's doctor's office should be able to help provide the right info and key words to get this approved. Here in CA, after you exhaust their appeal process, you can also do an external appeal (outside the insurance company). FWIW, on another insurance issue I was given the advice to call the insurance company and ask for a "case manager" who would be my single point of contact. That might help. In my case, I don't feel like she did anything for me, really. (she would make empathetic comments but not do anything internally to help. Maybe other case managers are better). Good luck!

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  • SuperFoob
    SuperFoob Member Posts: 505
    edited November 2012

    I have been Stage IV from the start. I have had 5 (maybe 6, my chemobrain forgets) PET/CT scans since May 2011. The 4th one was originally denied as I had already had 3 within one year. My Onc appealed and it was approved within a couple of weeks. I will be having yet another one in December. That is how my Onc keeps an eye on my insides, along with tumour markers.



    Like Peggy, I also have a Case Manager at my Ins. Co. (Anthem Blue Cross). I was assigned one when I was dx'd. It makes it easier to get info about my insurance and any issues. If your mom doesn't have a case mgr. she should ask for one.

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  • tviolet
    tviolet Member Posts: 2
    edited November 2012

    Thank you all for the advice, I will look into appealing this and getting her a case manager.Thanks so much

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  • cheryl1946
    cheryl1946 Member Posts: 1,308
    edited November 2012

    Like SuperFoob,I have been stage IV since the start. I had an initial scan last year for diagnosis,then one in April and end of September this year. Onc requests it for "restaging" of metastatic breast cancer.

    You need to enlist your onc in filing an appeal. The office is used to this, and should get approval.

    I have Health New England insurance with a Medicare Advantage HMO, and so far they have approved all meds and tests my onc orders.

    I recently requested a copy of all my meds since 1/1/12, and I got a copy of all tests,procedures,etc. What an eye opener that was! A PET/CAT costs $5250, plus $750 for radioactive tracer,$374for doc to read it. All I paid was $50 co=pay.

    I was astoinsed that my grand total for all my medical tests,dr visits (PCP ,onc,cardiologist) ambulance x2,ER,and hospital admission x1 (not cancer related) came to $56,799.82. I paid a total of $830 in co-pays.

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  • Rose12
    Rose12 Member Posts: 95
    edited November 2012

    I made sure my Pet scan was pre approved prior to the test. The girl in the office did it. Next time ask for pre approval before the test. That is the only way you will know if it is covered.

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  • peggy_j
    peggy_j Member Posts: 1,700
    edited November 2012

    I agree, pre-approval is important but please watch the language they use when they respond. I've been fighting to get my B-MRI pre-approved. They denied it, I appealed, and then they sent a response saying that pre-authorization was not necessary. Huh? I called to ask if that meant it was approved and they said "no" but that  I didn't need to wait for their approval before having the MRI. So sometimes even when you ask for pre-approval they might punt. arg!

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