PSMA/PET and MEDICARE

I know one person whose doctor is having him get a PET scan every three months with a .02 PSA. Normally, however, they will allow one every six months.

It seems that if the doctor requires it Medicare insurance will pay for it.

I’ve been told by my insurance company that the way it works with Medicare Advantage is that they evaluate the care needed for the people, Paying a larger lump sum for those that Have expensive medical requirements than those who do not. They don’t pay for each individual treatment in that case. Some Insurance companies are tighter about their spending so they might not allow a pet scan where another insurance company would.

Hi Jeff, I am on original Medicare and a supplement plan, I have no idea about how often Medicare will pay for PSMA/PET scans.

My husband is on Original Medicare and Dr. Kwon generally orders a PSMA PET scan for him every three months. Medicare has always covered it, no questions asked. I assume the key is that it is ordered by a provider in advance.

Is the PSMA PET scan the one I’ve called the PET AND CAT scan?

WOW that’s great to hear, I hope your husband is doing well. I just want to monitor the progress the ADT and radiation is having on the progression of the treatments, and not worry about a surprise rejection by Medicare and huge bill. Thank you!

What is a PSMA PET scan?
A PSMA PET scan is a type of nuclear medicine imaging that combines positron emission tomography (PET) with computed tomography (CT).
It uses a radioactive tracer that binds to PSMA.
The tracer is injected into the patient's bloodstream and travels to cancer cells expressing PSMA.
The PET scanner detects the radioactive tracer, creating images that show where the cancer is located.
PSMA PET scans can detect cancer in the prostate and areas where it has spread, such as lymph nodes or bones I hope that helps and sheds some light on it for you.

Yes I just didn’t know what it was called
3 months ago the said it spread to seminal glands but nowhere else.
The same doc from last test said not much change but a few “ shadows “ as if it wasn’t definitive then I’m notified that my doctor was changed and he’s the one that said “ THIS cancer will be the death of you” can two docs in the same clinic have such a different interpretation?

Seminal invasion is not considered outside the prostate, by many oncologists. My advice would be get the psma/pet scan and if it not outside the prostate including not outside the seminal vesicle. Get radiation ASAP, you have a great chance to end it right there.

Just a word about medicare traditional. Provider is required to have you sign an ABN in order to bill you for a non-covered test. If you sign an ABN its not covered. They can sometimes slip that in with the financial responsibility forms. Although the ABN is supposed to be test specific.

I will need to go to another facility since they say that “ you are not a candidate for radiation. And they explain nothing!
TY for the suggestion. I think you are correct!