Insurance rejection for PET

[Bev'sSister]

My sister's insurance company rejected her Doctor's request to do an PET. They said it would be investigative at this point? What kind of sense does that make. Has anyone any experience with this?

Should she go ahead and pay for the test? She is going to have a CT done today, but I am scared she really needs a PET. Will the CT pick up the same as the PET?

Any advice on this is truly appreciated.

Thanks,

Bobby

[mamasbabygirl]

Hmmm, if the Dr. thinks it would be a good idea, then I would go to the Patient Advocate Foundation and read up on what steps you can take to appeal this decision. You may have to get the Dr. to write out WHY she needs this test. The PAF website is very helpful-http://www.patientadvocate.org/ OR you could have her call the insruace company and ask about their appeal process.

I would not start paying for things out of pocket,NO WAY. I imagine a PET costs thousands of dollars, doesn't it?

[Kasey]

2-1/2 years ago my insurance refused payment for a PET. The gal at the pulmonologist's office told me before she even called to try to schedule it. They called it experimental and redundant since I had had a CT scan. Long story short - I went and had it done and said we would pay........HAD to have this done. Of course I didn't have to pay the day of the PET. I still filled out my insurance info and it was sent to them. It was denied 3 times and the doc's office kept resubmittimg. They were the BEST! The gal at the doc's office was awesome and finally faxed my whole folder (inches thick) to the insurance company. They paid. Interesting point here......if insurance paid for it, it cost $3600. If I paid............$2500. Still a lot of $$$$. But I never had to pay. I thnk they just try to get away as cheaply as possible. Keep advocating to get it paid for...but sounds as if you need to have it done.

Kasey

[trish2418]

I've had a PET every 3 months since diagnosis. My cheap as all heck insurance company has never denied payment. Could it be that her insurance company made a mistake? Have they paid for PET scans before?

I'd have the scan done and keep fighting the insurance company. Good luck.

Trish

[ztweb]

Bobby,

My dad docs at Mayo and because medicare does not pay for a PET (and never has) he has always had CTs. They are believers in them, and say that they listen to the patient about the rest of the body to watch for mets. He also generally has a brain scan to check there as well.

Best of luck.

Blessings,

Jen

[Bev'sSister]

She has had several PET's. I don't know what the problem is with this one, but I am told the Dr. talked to them himself and was unable to get an approval. She is going to have a CT, but I think her Dr. is going to insist on a PET also, and like everyone above has said, just fight the insurance company.

[teriw]

Bobby,

How frustrating. We haven't come across anything like this yet (not for a scan anyway). I'm wondering if the insurance company has some kind of time span they use -- do the PETs have to be so many months apart from each other? If her doctor really believes she needs one now, hopefully he can write some kind of justification.

Give your sis my best.

[ernrol]

Bobby,

Some insurance companies and Medicare will only approve a PET scan after a CT scan. The key words are "for restaging". Because of this I can no longer get a hybrid scan CT and PET combo. I get a CT scan then a PET scan a couple days later. If it states "for restaging" then it can't be investigative. Check with your doctors and see what they say. A PET scan will show things that a CT will not show. The spot on my hip for instance. I do think Medicare will pay for PET scans.

Stay positive,

Ernie

[EastCoastLadi]

Bobby,

my husband never had a problem as well, I've spoken to my brother who is a physician and he told me it is in the way the doctor "words" the order, because he does it all the time. I would have your sister speak to her dr. or the secretaries that do the scheduling for him/her and ask.

Grace

[Shelley (MLC)]

I have also heard stories that "some" insurance companies routinely reject many first claims, assuming some people won't bother to resubmit. (my sister worked for someone like that back in her college days!) I'd go ahead and have her apply again. Good Luck! Shelley

[ztweb]

I don't want make it sound like Medicare won't pay for a PET if they do. Maybe it is a Small Cell thing? We were specifically told that medicare wouldn't pay in my dad's case...whatever that case may be!!! Bummer.

Jen

[Flowergirlie]

I hate the politics of insurance companies. If you have insurance, it seems they should pay for what NEEDS to be done. My hubby did not have insurance so we had special circumstances but I just wanted to say I hope it works out quickly. I know when you have cancer or are a caregiver the first thing you want to do is fight in circles trying to get what you need to have taken care of with all of the extra time on your hands and lack of enough stress. (Kidding of course)

Restaging was a key word on all of my hubby's orders too though.

My Best...Flowergirlie