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

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.

I have been hearing this a lot lately. I go on Medicare next year and am trying to absorb all the info I can to be well prepared to make the right decisions. My friends get great perks on Advantage Plans but I’m learning the plans are not all they’re cracked up to be. 3 different medical billing people have now told me that I will get better service from non-Advantage plans. And they won’t deny me procedures and meds that are being denied to me now by my current health insurance.

FYI.....My doctor did reply back and state that a skeletal CT would be sufficient along with the biopsy and blood tests. All good. Would any of you care to elaborate on how it is that the distinction between MGUS, Smoldering and Active MM - are the blood test numbers - super high?

@puzzled211
It is confusing and there is a lot of literature out there to read. This was helpful to me about smoldering MM.
https://cancerblog.mayoclinic.org/2025/04/22/smoldering-multiple-myeloma-what-it-is-how-it-progresses-and-the-latest-research/
They are making new discoveries all the time, and there is good research going on. The treatment of multiple myeloma has advanced significantly in the last decade. I have MGUS, but when my physician visits with me every six months and goes over my lab results, he always ends our meeting by saying “don’t worry, if this ever advances to multiple myeloma, it is very treatable.” That gives me a lot of confidence to just be able to live my life and not suffer dread every day. Only 10% of patients with MGUS will ever advanced to multiple myeloma.
I hope these discussions are helpful to you. Will you check back in and let us know how you were doing?

Some insurance companies are more active deniers for expensive imaging, blood tests (especially genetic testing) and surgeries . Go on search engines such as DuckDuck Go, Startpage, don't use Google or Yahoo.

Ask what Medicare Advantage companies have terrible payment record.

I sell senior insurance and some companies I don't contracting with because of there poor payment rate or denials

@kobe2026 your search engine counsel is so interesting. Can you share why one should use the duck flock?

they give more truthful answers, Google gives the big pharm narrative
plus they are more serious about privacy

@suznsl I’m 73, but until I was 70 I continued to work and had a group insurance policy that was really good. Before I retired I researched Advantage plans versus Medicare supplements. I had already been diagnosed with MGUS and I am diabetic, but it is very well managed by medication.
I have friends who are on advantage plans, and they work very well for them, however, they do not have chronic illness to deal with. We have many physicians locally who will not accept advantage plans so their services are out of pocket, but they have had no trouble finding physicians who do accept their insurance. I do believe that you have a lot more flexibility in choosing the right specialist, however, should you need one with a supplement. In addition to what is subtracted from my Social Security by Medicare, I pay $180 a month for my supplement. I have had zero difficulty getting any medical care that I need. After I pay my deductible, I have zero out-of-pocket.
It’s a difficult decision because when you’re on a fixed income, your out-of-pocket expenses are a significant consideration. I am well satisfied with my decision to go with a supplement, however. If I want a second opinion, or I want to travel to a Mayo facility, I can do that easily.
I hope that your decision-making process isn’t too much of a pain and you are able to choose the right option for your particular needs.

YES - I'll update once I know something. Thank you for your reply.