› Forums › General Melanoma Community › Insurance denying payment of PET SCAN
- This topic has 21 replies, 7 voices, and was last updated 10 years, 8 months ago by
Tina D.
- Post
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- May 13, 2013 at 4:01 am
Hello,
My father has Stage IV Melanoma. I don't really know a lot of information, nor do I understand a lot of, but I want to help anyway I can.
I'm going to try my best to explain the situation, but like I said, I don't know a lot, so perhaps I will try and keep this more general.
Hello,
My father has Stage IV Melanoma. I don't really know a lot of information, nor do I understand a lot of, but I want to help anyway I can.
I'm going to try my best to explain the situation, but like I said, I don't know a lot, so perhaps I will try and keep this more general.
The insurance company denied payment for a PET scan my father had last August because they deemed it to be "not medically neccesary." He has appealed it and it is currently being "reviewed." I have been trying to do some research, and believe that PET scan application would clearly be classified as Staging, something that is in fact neccesary.
I feel that this scan was clearly neccesary and the insurance company is just trying to see what they can get away with. However, more recently, my father has had two more scans to see if it has spread further. If they deemed the August scan as not neccesary, I'm sure they will try and do the same with the two recent ones.
Obviously, the doctors need to prove the neccesity and write to the companies, but I wanted to know what others have done in situations like this.
Please share any advice/experience.
Thank you.
- Replies
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- May 13, 2013 at 5:09 am
Hi Leaf,
1. I am assuming we are talking about PPO insurance. Your doctor should have got pre-approval from the insurance company for this procedure. When I get my scans, I always get something in the mail before the date of my scan stating it has been approved as been medically necessary. You might want to confirm that your Dr. is doing this.
2. You have the right to appeal any decision made by your insurance company. You wuld need to call your insurance company and state you would like to make an appeal of a claim denial and ask to speak to a "greivance" representative. I have done this myself in the past and sucessfully won my appeal.
Hope this helps!
Jeff
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- May 13, 2013 at 5:09 am
Hi Leaf,
1. I am assuming we are talking about PPO insurance. Your doctor should have got pre-approval from the insurance company for this procedure. When I get my scans, I always get something in the mail before the date of my scan stating it has been approved as been medically necessary. You might want to confirm that your Dr. is doing this.
2. You have the right to appeal any decision made by your insurance company. You wuld need to call your insurance company and state you would like to make an appeal of a claim denial and ask to speak to a "greivance" representative. I have done this myself in the past and sucessfully won my appeal.
Hope this helps!
Jeff
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- May 13, 2013 at 5:09 am
Hi Leaf,
1. I am assuming we are talking about PPO insurance. Your doctor should have got pre-approval from the insurance company for this procedure. When I get my scans, I always get something in the mail before the date of my scan stating it has been approved as been medically necessary. You might want to confirm that your Dr. is doing this.
2. You have the right to appeal any decision made by your insurance company. You wuld need to call your insurance company and state you would like to make an appeal of a claim denial and ask to speak to a "greivance" representative. I have done this myself in the past and sucessfully won my appeal.
Hope this helps!
Jeff
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- May 13, 2013 at 3:58 pm
Hi Leaf,
Don't know if your father's insurance co is acting exactly like mine. But my PPO recently denied my last scheduled PET scan and insisted that my facility do a CT instead of a PET. At the Imaging facility, they said they've been seeing a lot of that lately from insurance co's, denying PET in favor of CT.
Did his insurance company have a CT done in place of a PET? Did anyone at your facility know or try to ask for a CT when the PET was denied?
At my facility they do most of the interactions with the PPO so they knew beforehand that the PPO had denied the PET and allowed the CT.
My doctor says hge prefers the PET, one thing he mentioned was he said it's better at spotting bone mets. I heard a webinar on this site with several oncologists. I think on average them say they didn't worry so much about whether a CT was done rather than a PET. One said she alternates PET or CT on whatever the scheduled interval is.
– Kyle
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- May 15, 2013 at 3:17 am
Thank you both for answering.
We've called the insurance company and doctors. Now we just have to wait for the appeal to be reviewed.
It's pretty clear that it was neccesary, but I fear that if they tried to get out of paying this, then this may be just be the beginning of us having to file appeals.
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- May 15, 2013 at 3:17 am
Thank you both for answering.
We've called the insurance company and doctors. Now we just have to wait for the appeal to be reviewed.
It's pretty clear that it was neccesary, but I fear that if they tried to get out of paying this, then this may be just be the beginning of us having to file appeals.
-
- May 15, 2013 at 3:17 am
Thank you both for answering.
We've called the insurance company and doctors. Now we just have to wait for the appeal to be reviewed.
It's pretty clear that it was neccesary, but I fear that if they tried to get out of paying this, then this may be just be the beginning of us having to file appeals.
-
- May 13, 2013 at 3:58 pm
Hi Leaf,
Don't know if your father's insurance co is acting exactly like mine. But my PPO recently denied my last scheduled PET scan and insisted that my facility do a CT instead of a PET. At the Imaging facility, they said they've been seeing a lot of that lately from insurance co's, denying PET in favor of CT.
Did his insurance company have a CT done in place of a PET? Did anyone at your facility know or try to ask for a CT when the PET was denied?
At my facility they do most of the interactions with the PPO so they knew beforehand that the PPO had denied the PET and allowed the CT.
My doctor says hge prefers the PET, one thing he mentioned was he said it's better at spotting bone mets. I heard a webinar on this site with several oncologists. I think on average them say they didn't worry so much about whether a CT was done rather than a PET. One said she alternates PET or CT on whatever the scheduled interval is.
– Kyle
-
- May 13, 2013 at 3:58 pm
Hi Leaf,
Don't know if your father's insurance co is acting exactly like mine. But my PPO recently denied my last scheduled PET scan and insisted that my facility do a CT instead of a PET. At the Imaging facility, they said they've been seeing a lot of that lately from insurance co's, denying PET in favor of CT.
Did his insurance company have a CT done in place of a PET? Did anyone at your facility know or try to ask for a CT when the PET was denied?
At my facility they do most of the interactions with the PPO so they knew beforehand that the PPO had denied the PET and allowed the CT.
My doctor says hge prefers the PET, one thing he mentioned was he said it's better at spotting bone mets. I heard a webinar on this site with several oncologists. I think on average them say they didn't worry so much about whether a CT was done rather than a PET. One said she alternates PET or CT on whatever the scheduled interval is.
– Kyle
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- May 15, 2013 at 5:44 am
This is ridiculous! I'd email my US Senator and Congressman. I know people don't do this, but it does make a big difference especially when its from lots of people.
My brother is an Attorney and continously works with insurance companies. He has the language they speak, he also has the patience to do so.
I have never been denied a PET scan from insurance, but their cost is ridiculous too… like $7,800. A CT Scan is much less and I'm not sure how much an MRI Is, but I think its still less than a PET Scan.
I had a PET Scan and it was wrong. It said I had cancer in my upper colon. I had an upper colonocsopy and there was nothing there.
I'm really sorry for your father. This disease sucks to put it lightly. I wish you the best in getting your scan.
I'm out since 1984, Mets in 2005, still here!
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- May 15, 2013 at 5:44 am
This is ridiculous! I'd email my US Senator and Congressman. I know people don't do this, but it does make a big difference especially when its from lots of people.
My brother is an Attorney and continously works with insurance companies. He has the language they speak, he also has the patience to do so.
I have never been denied a PET scan from insurance, but their cost is ridiculous too… like $7,800. A CT Scan is much less and I'm not sure how much an MRI Is, but I think its still less than a PET Scan.
I had a PET Scan and it was wrong. It said I had cancer in my upper colon. I had an upper colonocsopy and there was nothing there.
I'm really sorry for your father. This disease sucks to put it lightly. I wish you the best in getting your scan.
I'm out since 1984, Mets in 2005, still here!
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- May 15, 2013 at 12:04 pm
Hi Cindy! Congrats on sticking around so long, that is inspiring to many of us!!! Would you be so kind as to complete your profile? Situations like your can be so encouraging for those of us looking for hope.
Thank you.
Holly -
- May 15, 2013 at 12:04 pm
Hi Cindy! Congrats on sticking around so long, that is inspiring to many of us!!! Would you be so kind as to complete your profile? Situations like your can be so encouraging for those of us looking for hope.
Thank you.
Holly -
- May 15, 2013 at 12:04 pm
Hi Cindy! Congrats on sticking around so long, that is inspiring to many of us!!! Would you be so kind as to complete your profile? Situations like your can be so encouraging for those of us looking for hope.
Thank you.
Holly
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- May 15, 2013 at 5:44 am
This is ridiculous! I'd email my US Senator and Congressman. I know people don't do this, but it does make a big difference especially when its from lots of people.
My brother is an Attorney and continously works with insurance companies. He has the language they speak, he also has the patience to do so.
I have never been denied a PET scan from insurance, but their cost is ridiculous too… like $7,800. A CT Scan is much less and I'm not sure how much an MRI Is, but I think its still less than a PET Scan.
I had a PET Scan and it was wrong. It said I had cancer in my upper colon. I had an upper colonocsopy and there was nothing there.
I'm really sorry for your father. This disease sucks to put it lightly. I wish you the best in getting your scan.
I'm out since 1984, Mets in 2005, still here!
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- August 30, 2013 at 6:17 am
Lots of pet parents have heard about pet insurance but have avoided looking at it, often because they've been told something that isn't quite correct. We tackle six pet insurance myths and set you straight. Dan Jones -
- August 30, 2013 at 6:17 am
Lots of pet parents have heard about pet insurance but have avoided looking at it, often because they've been told something that isn't quite correct. We tackle six pet insurance myths and set you straight. Dan Jones -
- August 30, 2013 at 6:17 am
Lots of pet parents have heard about pet insurance but have avoided looking at it, often because they've been told something that isn't quite correct. We tackle six pet insurance myths and set you straight. Dan Jones -
- August 30, 2013 at 5:20 pm
How incredibly frustrating. I have been fortunate to never have our insurance question any scans, though I do joke about them sending snipers out after me because I have cost them so much money. Scans are a necessary part of the whole process, I do not see how you could possibly not win an appeal effort. SO sorry you have to deal with this added stress.
Tina
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- August 30, 2013 at 5:20 pm
How incredibly frustrating. I have been fortunate to never have our insurance question any scans, though I do joke about them sending snipers out after me because I have cost them so much money. Scans are a necessary part of the whole process, I do not see how you could possibly not win an appeal effort. SO sorry you have to deal with this added stress.
Tina
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- August 30, 2013 at 5:20 pm
How incredibly frustrating. I have been fortunate to never have our insurance question any scans, though I do joke about them sending snipers out after me because I have cost them so much money. Scans are a necessary part of the whole process, I do not see how you could possibly not win an appeal effort. SO sorry you have to deal with this added stress.
Tina
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