Is a PSMA PET SCAN the next step

Sorry to hear about this, last thing you need in this situation is to have to fight the insurance companies for imaging you need.

I really don't know anything about Medicare, but, my private insurance initially denied mine as well. What you might be able to do if you have the resources is negotiate with the provider for a cash price. This is what I did. After having the scan and paying about $.60 on the $1.00 for it, the insurance company ended up paying for it. I have no idea what turned the tide there.

Oddly enough, the fight to get my cash back from the hospital was tougher yet!

Best of luck to you!

I am sorry to hear this, you have insurance and cancer and having this stress is not correct. Shame on the industry! I have BCBS and in order to get a PSMA PET I had to do it in sequence starting with Bone scan, then MRI scan, then CT scan, then they approved the PSMA PET. What information have they provided for their rationale? For example, to qualify for Pluvicto, you first need to have done ADT and Chemo, then you can get Pluvicto. I'm wondering if there is more data available. (?).

Ken:
Continue to appeal the denial.
I infer that your Dr, hopefully Surgeon, RO or MO, are supportive.
And you may need to have intermediate steps such as a bone scan, if that is the administrative process.
My Urological Surgeon ordered a MRI (PRADs 4 & 3), followed by a fusion guided biopsy (G 9, 8s + more). And then a PSMA PET to determine if there were metastases before surgery.
I have Traditional Medicare, but the coverages are the same with Advantage plans.
Persevere. It is frustrating, but not futile.
Best wishes.

While not on Medicare, I do have a BCBS plan of my own. They had no problems with my PSMA PET SCAN last year and paid their portion of the claim without issue. I was told by my own navigator at the local cancer center where I was treated that they often get better results if they do an appeal, since they can provide the medical basis for the treatment. For example, my Decipher test was rejected initially for "no prior authorization" and "out of network" last winter, The cancer center took over the appeal and got paid. Don't give up, and lean into your care team to advocate for at least some coverage.

Odd as both my Psma scans were covered by medicare
I’m on Medicare original with supplemental blue shield

Hey Ken, sorry for your situation. I have friends (not on the forum) that have Medicare Advantage and have had the same struggle. I have traditional Medicare and have had to receive two PET-PSMA scans and have had near zero out of pocket costs. I had piss poor private insurance prior to receiving Medicare and they wouldn’t pay for anything but a standard 12 core random biopsy which, according to my oncologist was a recipe for disaster. My point in sharing this as I understand your situation.

You may want to consider or at least investigate switching to traditional Medicare either after you get treated or before. Here’s a link on how to do that: https://www.kff.org/faqs/medicare-open-enrollment-faqs/how-can-i-switch-from-medicare-advantage-to-traditional-medicare-is-there-a-form-i-need-to-fill-out/

Good luck on your journey. Don’t be afraid to be your own advocate, even if that means calling so frequently that they get tired of hearing from you.

And remember, we’re here for you.

- Bob

I was also Gleason 7 (4+3). Had my PSMA scan at Mayo Rochester in May and Medicare paid it. I have regular Medicare. I had heard too many stories of MA plans turning down things Medicare pays for. Keep appealing!

Bob, thank you so much for your reply. I think the Advantage Plan is the problem. When I had bladder cancer I had a Medicare Supplement plan and never had a problem. My expense was through the roof for 5 years. Four surgeries, endless cystoscopy, CT scans and chemo. All paid by the plan. I ran a tally back then and figure the cost to be over $300,000. I better take a look at getting back on that plan. Thank you Bob.
Ken

Thanks for all the excellent replies. web265, edmond1971, michaelcharles, ScottM, mammoth3414, clandeboue1, robertmizek, and jfc58.
Just got a call this morning (8/13/24) from Blue Cross Advantage informing me my “appeal” has been reopened for consideration and I will hear something “soon”. Whatever soon means. They know I’m not going away, in the last 7 weeks I have made 33 telephone calls to Blue Cross, Urologist office, and Carelon (3rd party decision maker for Advantage plan. If I get refused again I will start a massive harassment campaign and might get my congressman involved. Not giving up this fight 👍🏻👍🏻👍🏻..

I think the issue is probably your Medicare Advantage Plan. I have traditional Medicare with the AARP UHC Plan F and have had 3 PSMA Pet Scans and never had an issue with approval or payments.