• From: Connecticut
  • Registered: Thu, 18 Nov 2010
  • Posts: 68

Topic: PET scan denails?

Hi everyone,

My mom was just informed at my Dad's last chemo treatment that their insurance company (I believe they have a Cigna PPO) now refuses to pay for PET scans unless they are for initial diagnosis. The nurse/receptionist said that this is a new thing that many insurance companies have implemented as of January 1st, 2011 in the US.

Has anyone else heard of this? Or is is just their certain insurance? I'm afraid they don't have many other options for insurance since its through my Dad's company and he is currently on Long Term Disability.

On a side note: his Dr is going to try to bargain with the insurance to approve it anyways once he needs another one, but I'm just so surprised that they would do this when clearly a PET scan is so much more effective than an MRI or CT scan with this type of cancer. (Well, no, im not surprised. Insurance companies are you-know-whats).

I lost my Dad to CC Feb 13, 2011 at 7pm EST. I felt him take his last breath. He was 57.
I love you, Daddy.

--Kim
  • Lainy
  • Lainy
  • Moderator
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  • From: Phoenix AZ
  • Registered: Fri, 13 Jan 2006
  • Posts: 8,209

Re: PET scan denails?

Hi Gracefulmeadows, crazy, it's just crazy! Teddy was having PETs 2 times a year for several years and they denied him twice. When the ONC went to battle for him he won. I also have a rare Cancer and need PETs, sometimes twice a year and only had to battle once. More recently my ONC put in a request when I saw him in November, for this month, and I got it, no problem. Teddy was on Cigna I am on Secure Horizons. So answer may be the ONC has to fight for it. At one point when I thought they were really not going to come through I searched for independent places in Phoenix that gave them at a reduced rate and did find one that in the end the charge would be $1600.00 and I was going to make the appointment when the OK came through from CIGNA. Good luck.

Teddy ~In our hearts forever~ATTITUDE is EVERYTHING
Any suggestion I offer is intended as friendly advice based solely on my own experience. Please consult your doctor for professional guidance.
  • From: Connecticut
  • Registered: Thu, 18 Nov 2010
  • Posts: 68

Re: PET scan denails?

Thanks Lainy. It makes me so mad that they would deny this certain type of scan. Clearly the $4000 out of pocket is absurd and nobody can afford that on top of all the regular insurance payments! If his ONC can't get it approved, we'll have to ask him about other centers around here that may offer it at a discounted rate like they have in your area. But still...$1600 is a lot of money for something that the insurance SHOULD cover.

I lost my Dad to CC Feb 13, 2011 at 7pm EST. I felt him take his last breath. He was 57.
I love you, Daddy.

--Kim
  • Registered: Sun, 14 Nov 2010
  • Posts: 295

Re: PET scan denails?

GracefulMeadow - My son had a procedure known as chemo-embolization at Johns Hopkins in Baltimore, MD.  The day before it was scheduled, I received a call from the scheduler at the hospital saying that his insurance would not pay because it was not an "approved procedure for cholangiocarcinoma."  It's a long story, but eventually, the doctor said he would do it for free.  At the last minute, the insurance company decided they would pay.  He had a second chemo-embolization and we had to go through the same thing all over again.  When I discussed it with the insurance company, I asked what procedures were approved for cholangiocarcinoma - and they told me, "Well, none, because it is so rare."  I wanted to scream!!!  BUT - in the end - they did pay and I know the surgeon had to have many conference calls with them first.  It's just awful what you have to go through, but be persistent and fight - fight - fight! Good luck! (P.S.  You have the right to appeal their denial as well -- my niece had something denied and appealed three times and finally won)! - Nancy

Mother of John who lost his battle on Oct. 9, 2009 at age 30....
  • Registered: Fri, 12 May 2006
  • Posts: 8,160

Re: PET scan denails?

GracefulMeadow.......Does the insurance company pay for a CT  scan or MRI post initial diagnoses.? 
Best wishes,
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER
  • From: Connecticut
  • Registered: Thu, 18 Nov 2010
  • Posts: 68

Re: PET scan denails?

nur1954, I can't believe they wouldn't cover things because CC is rare!!!! That's absurd! But i'm glad that you have the right to appeal. Seems we'll be doing that a lot!

marions - yes, the insurance company pays for CTs and MRIs post diagnosis...or at least they did last year. Hopeuflly that hasn't changed but now we can't be assured of anything with these jerky companies.

I lost my Dad to CC Feb 13, 2011 at 7pm EST. I felt him take his last breath. He was 57.
I love you, Daddy.

--Kim
  • Registered: Fri, 12 May 2006
  • Posts: 8,160

Re: PET scan denails?

GracefulMeadow......When looking back at some of our historic postings I found more problems with insurance coverage for a PET scan than for CT and MRI.  You might also want to read up on a few by using our google function, top right, enter: PET scan.  We have several threads regarding this subject.  Perhaps you will find some hints or tips, as to how you move forward with the insurance.  Hopefully, others will chime in and share some of their thoughts.
All my best wishes,
Marion

THIS INFORMATION IS NOT INTENDED NOR IMPLIED TO BE A SUBSTITUTE FOR PROFESSIONAL MEDICAL ADVICE. YOU SHOULD ALWAYS SEEK THE ADVICE OF YOUR PHYSICIAN OR OTHER QUALIFIED HEALTH CARE PROVIDER
  • From: Connecticut
  • Registered: Thu, 18 Nov 2010
  • Posts: 68

Re: PET scan denails?

Thanks Marion! I'm going to do that today and hopefully get some good info that other people have used to get them to approve.

I lost my Dad to CC Feb 13, 2011 at 7pm EST. I felt him take his last breath. He was 57.
I love you, Daddy.

--Kim
  • LeeAnn
  • Senior Member
  • Offline
  • Registered: Mon, 30 Jan 2012
  • Posts: 94

Re: PET scan denails?

Same problem here.  I was schedule for pet/ct and ct tomorrow but got a call saying that insurance denied pet/ct. They(imaging center who works for insurance) talked to my onc and approved ct only and based on ct result they will evaluate again for pet.  Another delay tactics from insurance company...