Insurance denied petscan? All research shows it sb done, what next?

Putting this out there so anyone who has challenges getting things approved - this is what I found out today. BCBS did not deny but it was the 3rd party they use that denied my petscan. BCBS connected me to them and I explained my whole story - she said the dr did not even do a peer to peer with them. She said most likely they (3rd party) want more information like blood tests. She gave me their direct# and case ref# and I gave them back to the doctors nurse and asked them to make this happen. Perhaps the dr is so busy and did not take the time - I do not know but that is a bit frustrating. The response I got back was the skeletal CT scan sb sufficient along with the bone marrow biopsy.....but what I see on the web from Sloan Kettering Hospital and Cleveland Clinic and Mayo as well - is that the petscan is an integral part along with the BMB because it is possible that the spot they pull the biopsy from may not have the bad cells in that spot which is why a petscan is also needed as it sees all of the bones on in the inside. The skeletal CT shows if any lesions are on the bones on the outside.....SO. I have asked the doctors office to push this today as my insurance changes 8/1 and I need to know what I am dealing with. QUESTION - Am I being unreasonable....

Putting this out there so anyone who has challenges getting things approved - this is what I found out today. BCBS did not deny but it was the 3rd party they use that denied my petscan. BCBS connected me to them and I explained my whole story - she said the dr did not even do a peer to peer with them. She said most likely they (3rd party) want more information like blood tests. She gave me their direct# and case ref# and I gave them back to the doctors nurse and asked them to make this happen. Perhaps the dr is so busy and did not take the time - I do not know but that is a bit frustrating. The response I got back was the skeletal CT scan sb sufficient along with the bone marrow biopsy.....but what I see on the web from Sloan Kettering Hospital and Cleveland Clinic and Mayo as well - is that the petscan is an integral part along with the BMB because it is possible that the spot they pull the biopsy from may not have the bad cells in that spot which is why a petscan is also needed as it sees all of the bones on in the inside. The skeletal CT shows if any lesions are on the bones on the outside.....SO. I have asked the doctors office to push this today as my insurance changes 8/1 and I need to know what I am dealing with. QUESTION - Am I being unreasonable....

I went to a myeloma specialist. She ordered the bmb and body ct scan. Next year, and every year after, I will have a pet scan. I am smoldering.

That's interesting. I've had multiple myeloma for a year now. I've never had a Pet scan. My doctor said it wasn't necessary. I've had lot of MRI's and CT scans. I even did a complete work up at Mayo Rochester before my stem cell transplant in January. Still no PET scan.

Thank you amber199 - May I ask how did they confirm smoldering? The biopsy or blood tests???

Medicare Advantage (MA) plans are required by law to cover all services that Medicare does, but they make their own determinations as to what care is "reasonable and necessary". People should be aware that there is definitely an issue with MA plans denying care that Medicare would permit. See, for example, https://jamanetwork.com/journals/jama-health-forum/fullarticle/2815743 A couple of years ago, the HHS Office of Inspector General found that MAs "sometimes delayed or denied Medicare Advantage beneficiaries’ access to services, even though the requests met Medicare coverage rules". https://oig.hhs.gov/oei/reports/OEI-09-18-00260.pdf

Are they supposed to do that? Nope. Do they do it? Yep. MAs exist to make a profit. Remember that when you decide between original Medicare plus a medigap and an MA.

So why is nothing done about it? Well, insurance companies have lots of money - certainly more than patients or providers - and are not shy about spreading it around.