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Insurance denial of PET/CT scan

Posted by mimighosh @mimighosh, Sep 5, 2024

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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Teresa, Volunteer Mentor | @hopeful33250 | Feb 22 11:08am
In reply to @gangcarotid1 "@mimighosh My son, now in his 40s, was born w a bilateral cleft lip and palate...." + (show)
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@mimighosh
My son, now in his 40s, was born w a bilateral cleft lip and palate. We had very good Blue Cross Blue Shield insurance from the time he was born and through the 26 yrs of surgeries done as his face grew (the nature of reconstructive surgeries for this congenital anomaly) we went to Mayo for the LaForte osteotomy and BCBS refused to cover, calling it 'cosmetic surgery'. The then head of the Maxillofacial Dept, Dr Keller (who developed the LaForte osteotomy procedure, and did Michael's surgery) wrote a scathing letter to BCBS on our behalf, even referring to BCBS Idaho as having a third world country mentality, as this surgery was for helping Mike improve his eating and breathing function. I also found in our 244 pg contract where BCBS said one thing 180° different from what they wrote in another part of the contract. The Idaho Insurance Commission and their attorneys called this gross harassment and advised the co pay 100% or any ensuing lawsuit would result in free health insurance for the entire family for life. They paid, and there's now an Idaho law that says any insurance co practicing in Idaho will cover any reconstructive OR cosmetic surgeries regardless of past insurances coverage; I call it Michael's Law. Those drs at Mayo are fierce advocates for their patients. As an aside, who knew, I'd have a tumor removed from my carotid artery 15 yrs later, by Dr Keller's successor?
Bottom line, don't give up! Best wishes for success.

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Hello @gangcarotid1

I appreciate your encouraging post on handling insurance denials. Your doctor at Mayo was certainly a strong advocate for your son's surgery. This brought up an important point that often, doctors can be very effective in handling insurance problems. My pulmonologist went to bat for me regarding an inhaler that I needed to control my asthma.

It requires everyone's persistence to make this happen. I'm happy that you were so successful and have posted about it on this forum.

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gangcarotid1 | @gangcarotid1 | Feb 22 12:18pm

I'm so very grateful and thankful to my doctors at Mayo, as well as things forum. Anything I can do to further Mayo's goals, I'll do it.

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