I am fairly certain that I read in the Medicare rules that you can only have three PET scans for the same "condition." I've had 2 so far, and my MO has now scheduled a CT, telling me that Medicare won't pay for a third (which I believe is incorrect). She said that they would pay if there was a change in circumstances, so maybe that's the kicker?

Good luck, and let us know what you find out.

Just chiming in. All so blasted confusing.

I had read on here (BCO) that a person can only have 3 PET scans in a lifetime with Medicare in the U.S. Don't know if that is true.

My health insurance (thru my work) allowed me to have 1 PET at diagnosis for the baseline testing. Denied another 1 year later (wanted yearly PET). NOW my insurance is balking at 3 month CT's. Denied latest one and MO had to call insurance company and do a peer to peer phone call. If this one stable, don't know what insurance will say in 3 more months.

Jobur-- I see you are from Wisconsin. I am Illinois. Close in terms of area of U.S. Don't know if that matters. And you are bone/liver like me.

JFL- PET'S EVERY 3 MONTHS FOR 4 1/2 YEARS !!!! Wow. I don't know what area of the country you are. Also you are bone/liver like me.

I do not understand how insurance companies can be so different in what they will allow. I wish we could do at least a yearly PET for me. Each type of scan shows a little different thing about the cancer and all I get is the CT's. If my insurance will allow that !!!!!!!!!!!!!!!

I asked my PA this question just last week. I am covered by Medicare and a supplemental plan. She stated that most insurance will cover PETs, but was sure if several (never stated a number) went by with no evidence of disease insurance would stop covering. She also said once you switch to CT scans the only way to warrant a PET is to have disease progression. I have had four PET scans so far and a fifth is on the horizon. The only bad one was the very first. I do worry some about the cost and the amount of radiation being stored in my body. Guess it is worth it for the certainty of the test. It is amazing how different insurance companies see diagnostic tests.

Not on Medicare yet, but there could be a difference if one person has a Medicare Advantage plan and another has regular Medicare with a supplement, isn't that correct?

As I understand it, the Medicare Advantage plans are private plans and they have leeway in what they cover. although there are some minimum guidelines set by the government.Also, there could be regional differences because there are regional boards or bureaus that decide what is covered and/or how much reimbursement providers get.

Candy, I am in Florida, which has notoriously AWFUL health care administration. I do think that my MO does play a part in that he told me at some point that he usually has to get on the phone with the appeals rep at the insurance company (who is an MD) and speak to the rep but that a convo is always sufficient to get it approved, so long as the PET is coded as "restaging". My MO pushed back on me getting PETs in the beginning because he thought I would have insurance trouble. I told him I wanted to try and reassess if they were denied. I have been denied coverage of many things from my insurer that I thought should have been covered but for some reason, I have never had an issue with scans and in other instances, scans have been covered for medical services that insurance doesn't cover (like my scans I received when I had IVF 5 years ago - the IVF doctor told me that they would not be covered and I would have to pay them out of pocket like the rest of the IVF fees). I asked the clinic to submit them to my insurance and all were covered with no questions asked. Saved me thousands of dollars. Not sure what the deal is but I will ride this wave as long as I can. Also, my company is self-insured although administered by a large insurance company. It is possible my company set up different rules/thresholds and their rules around scans are more inclusive than the large insurance company would have for itself if it were the actual insurer.

ok, even though I'm not on Medicare, this sounds like the same procedure my doctors office has to go through. The first scan I had went through with no problem but the second PET we scheduled was denied and they were going to use some other imaging for me but I managed to get the assistant to tell me that a peer to peer call could be done. Then I made it clear to my doctor that I wanted PET scans...not a CT. So now I get them every time. They do deny first whe the pre-auth is sent but then they do the call and it gets approved.

I also called my ins. Co. as you did and found out the name of the third party approval company. Then I googled them. Their provider manual is online in PDF format and it shows the criteria for “advanced imaging service" approvals. And their manual pretty much says what you just wrote in regards to PET scans for bone mets, jobur. I told my doctor if ever they don't want to approve the PET on a peer to peer call, she should refer them to their own literature.

So try googling that third party company and you may find their manuals online like I did. Best of luck with this, now that you've figured it out you should get what you need.

JFL- Help me understand "restaging". I have heard that term before, but do not quite understand how that works with the scan ordering. Yep ride the wave as long as you can.

Jobur- Good summary. Thank you for summarizing it. That helps. As far as my CT denial, my insurance company has a third party authorization company also. I have not called them yet. I am going to wait to see if this CT is stable or not. If progression and change in treatment, then the next CT should be approved, right? But if stable, then I plan on investigating the why of the denial. I am going to ask MO her story (what was said in peer to peer phone call) and then call the third party company and asked them their side and get the policy in writing. I am freaked out about my CT denial because if they continue denying then how will we check for progression in the future????????? The CT's is the only scanning I get.

I don't worry much about the radiation exposure. I have Stage 4 cancer so the horse is out of the barn. And the cost to the insurance company doesn't worry me in the least. The administrators are making big salaries while I have Stage 4 cancer at the age of 49 !!!!! Boo freaking hoo for the insurance companies.

Jobur and others- I looked up my third party authorization company's clinical guidelines PDF online. It states the indications for each test to be ordered i.e. following up on cancer while on active treatment, but did not give specifics on how many per year or how often each specific test can be ordered. I will reread and print off for future use. But not too helpful so far, in my opinion. Probably vague on purpose.

I did look up NCCN Guidelines for Imaging and printed that too. But lots of leeway i.e. endocrine therapy use- a CT can be ordered every 2-6 months. I do every 3 months, so in that time frame but could go to every 6 months and would still be in the window. But I don't want to go every 6 months with organ involvement - liver. As far as PET's, which is the topic of this thread, NCCN Guidelines say "optional" under "PET scan". Interesting.

Will do more research.

Hi,

The Affordable Care Act of 2010 eliminated lifetime limits for essential services. So, I am not sure how your insurance company can limit your coverage for PET scans. There is a lot of info online about this. I just found this site, but there are many others. Good luck . https://www.thebalance.com/lifetime-maximum-2645768#targetText=Since%202010%2C%20policies%20issued%20on,yearly%20maximums%20on%20essential%20services.