PET Scan

My Mayo Oncologist ordered a PET scan last September because I have metastatic (one met) prostate cancer. He wanted a baseline etc. as we progress thru the various treatments and drugs. I was shocked when MEDICARE denied initial payment so I appealed the decision and was denied again eventhough the Onco submitted a letter stating the necessity etc. of the scan. MEDICARE stated the records submitted for review do not support the medical necessity for the scan. If metastatic PCA does not qualify for payment of the scan.

I am baffled and not happy that I will have to pay approximately $1500 for the PET scan. Any advice, comments, suggestions much appreciated. The Old Sailor

My good friend Sailor, ltns.

Sorry to hear of your denials for the PET scan. I had one done last September, ordered by my Oncologist. I was under Medicare alone at the time, and they approved it instantly. Like you, my doctor wanted to check for mets, as I too have metastatic PC at this point. There was no problem. Don't understand why you would be denied. I have had 3 MRI's done since September, and Medicare approved all of them without question.

I would think your doctor's office should be able to intervene on your behalf to see if they can get an approval for you. My doctor had to do that recently when my new neurologist ordered an unusual scan, and again, Medicare approved it.

I have a picture of our friend Pio looking at me in my living room, reminds me of you, he watches over you too.

David

There are PET scans and there are PET scans. If it's Mayo, it's probably the C11 Choline PET scan, which I have yet to hear has ever been approved by Medicare. You might have a better chance getting an NaF18 PET scan approved. They might approve an FDG PET, but that's not likely to be very useful at this stage.

- Allen

Is it possible that your Mayo Doc wanted it for the purpose he stated {baseline}and not that it was a critical scan at this point in time. I mean if he can get it approved, why not. If not , oh well… Why pay 1500 for a nice to know and not a need to know. I have no idea, which of the 2 it is, but he certainly does. Has He shared that information with you? The letter to Medicare he wrote is not definitive proof that he thinks it is need to know. Just office billing technique imo. If you are of the view that any and all tests can add value to your journey willy nilly, and therefore needed, disregard this post….

Old Sailor,

Medicare approves NaF PET as long as it is written up to conform to their guidelines as an experimental procedure. Here are their guidelines:

National Coverage Determination (NCD) for Positron Emission Tomography (NaF-18) to Identify Bone Metastasis of Cancer (220.6.19)

Your doctor has to agree to file your data as part of a research study with the National Oncological PET registry.

- Allen

Post Edited (Tall Allen) : 2/5/2014 10:07:07 AM (GMT-7)