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Molecular studies as necessary medical treatment
My insurance company has denied payment for the molecular studies on my tumor due to “not medically necessary”. I am writing an appeal and need articles to back up my claim that it is necessary for pancreatic cancer with liver metastasis. Has anyone had this happen and do u have any articles to share?
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Are you saying that your insurance company won't pay for the pathology of your tumor to determine which mutations you have? Please clarify "molecular studies".
Yes. They denied payment and the reason is “not medically necessary”. They paid for the genetic studies but not the molecular studies. The cost was $20,000. I am appealing this decision and my oncologist is writing a letter as well.
I would like to know where you are receiving your care as it sounds absurd to me. You need to know what your pathology is in order to receive the best treatment that is directed to your mutations. You can have somatic tumors that aren't germline (inherited). It sounds like you don't have Medicare yet? I have a Medicare Advantage PPO Plan and they have been an excellent payor. I wish you luck in your appeal, but you certainly shouldn't have the extra stress at a time like this.