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Insurance denial of PET/CT scan
My husband was diagnosed with grade 1, stage 4 NET in Feb 2024. A PET/CT scan was used for confirmation of this diagnosis. Although the physician thinks this was a necessary scan (and has provided a letter of medical necessity), the insurance company has denied the claim. Meanwhile, the private company who performed the scan has billed us for the full amount ($6000) and send this bill to a collection agency while we were waiting to hear from the insuance appeal. Unfortunately, my husband did sign a waiver before the procedure stating that we have to pay if the insuarance does not. At the time we were anxiously waiting for this diagnosis and did not fully appreciate the implications.
I was wondering if anyone else has expereinced this and how they managed.
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I'm sorry you are going through this. I suggest you take the following steps:
1. Contact your insurance company to appeal their decision. They have a formal process for reviewing decisions. Keep all correspondence in this appeal.
2. Contact the company who provided the scan and notify them that you are appealing and ask that they halt collections pending the appeal. Include any documentation of the appeal including the insurance company's time frame for resolving the issue.
3. If the insurance company upholds their original decision you may continue to appeal but the mechanism depends on whether you have an employer sponsored plan, Traditional Medicare or Medicare Advantage. If an employer sponsored plan or an ACA plan then I would recommend copying your State's insurance commissioner.
It is a bureaucratic process by design but you can get a good result.
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3 ReactionsI'm pretty sure a PET scan is needed to see all the locations of your NETS. I would definitely appeal to your insurance company. I had a PET Scan for my NET diagnosis in January 2023. IHC hospital here in Utah billed my insurance $27,000 for this service, is 4.5X the cost of yours. Our heath care system is broken. The range for my MRIs has been $550 to $2300 in the same system.
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1 ReactionIm so sorry you have to deal with this on top of the diagnosis.
You might get some helpful information from
https://theinsurancewarrior.com/
She has excellent advise and will even handle an appeal for you (for a cost, I’m sure but may be worth it)
I have her book and found it really helpful
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2 ReactionsI agree with the calling of your state insurance commissioner. We did that when our son had a LaForte osteotomy tied to the malformation of his jaw from cleft lip & palate. The Dr at Mayo also wrote a scathing letter to our insurance company about it being a correction of acongenital defect, not something only cosmetic. When we were denied the second time, I sent a copy of the surgeon's letter to the insurance commission office, and they enlisted their 7 attorneys to fight it. Final recommendation to the insurance company for the bill by the attorneys was to pay the bill in full or they would be in court where the verdict would be that "this family may very well end up w total coverage for life due to the extremely gross emotional harrassment". They paid the entire bill WITHOUT a deductible, Very best wishes to you!
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4 ReactionsAlso wanted to mention that a new law was subsequently passed in our state that says any insurance company operating in our state will completely cover all surgical correction for congenital birth defects to the satisfaction of the patient(, even regardless of past coverage!) I call it "Michael's Law".
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3 ReactionsThank you all so much for all your suggestions. We will definitely try out some of these strategies. A friend of ours suggested we find a nurse navigator or a patient advocate to help us with these battles. I am happy to say we did connect with a nurse navigator last week through the "life with cancer"program at Inova Fairfax, and so far she has been wonderful.
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2 ReactionsOne more suggestion is to contact the doctor's office who requested the PET/CT scan. There is a possibility that the doctor's office did not fill in correctly the paperwork or they need to add details, etc...
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4 ReactionsGreat steps.
In addition, discuss with dr office that generated the order. Perhaps medically necessary dx code was omitted, or more documentation is required for insurance.
First, don’t worry. It will be handled. We’ve been thru this.
Contact insurance company to determine why denied and next steps.
Discuss with dr office that generated the order. Perhaps medically necessary dx code was omitted, or more documentation is required for insurance.
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3 ReactionsHi, thank you for your comments!
We are in a strage sort of situation with this. The Insuarance says that the Radiology company is an in-network provider with them and they have a contract agreement. The insutrance is still saying that this was a medically unecessary procedure ( in spite of a letter from the Dr.), but they also told us that because of this agreement with the company, we are not obligated to pay them anything. However, the company argues that we signed a waiver, therefore, we are required to pay the whole amount. Right now, the insurance has asked for additional details from us, including a copy of the waiver we signed and a bill from the collection agency. We are waiting to hear from them about the next steps.