Anyone have trouble with BC/BS denying a PET scan as investigative? Our neurologist did every test under the sun over year's time and finally ordered a PET scan, following a repeat neuropsychological (all day) exam repeat, to figure out if my DH had Fronto-temportal dementia or AD. Test results were mixes. Neurologist followed Medicare guidelines (although DH is too young for Medicare). Dr. was surprised when our BC/BS turned down the claim. He says that Medicare and other insurance companies have paid in similar instances. We've hired an attorney, used by another AD person we met in support group because he also had BC/BS denied a PET scan claim as investigative.
So if you run out of tests to do and your neurologist recommends a PET scan, the latest diagnostic tool...I would suggest you get a pre-approval from your insurance company. We are too late smart!
If anyone has experienced this 'denial' issue and has any ideas besides an attorney, I'd love to hear them.
Out of curiosity are you guys in California? Where they denied my husband permission to go to a cardiologist after his pacemaker operation. And where it took me a year to get to a gynecological oncologist. Because if you are, it does not surprise me.
4 years ago, when we were first studying DW, I suggested a PET scan and our PCP ordered it. The technician at the lab then called to tell me that medicare would not pay for it and I had to pay $3000 up front. Needless to say, we passed on that test. I felt the diagnosis was sufficiently firm that I didn't need the additional expense. The medicare rules may have changed since then.
Yesterday, my husband had his 2nd PET Scan, thankfully the insurance paid for it. I have found that I never agree to any test (except blood) without pre-authorization. I learned my lesson a few years ago when I thought I went through all the correct channels to have the Neuropsychological testing done, and the insurance denied the claim. Thankfully, the doctor & a thoughtful hospital medical adjustor fought for it to be paid, after a year of many phone calls they finally decided to pay. All this and my husband walked out after about 30 minutes of testing, he thought they were too condescending.
The neuro and the clinic warned us that the PET scan would not be covered if we said that it was to test for AD, and I was to go along with what the orders said when I signed the paperwork. I can't remember exactly what they did put on the orders ... maybe something about problems with balance? and it went through OK.
(The inconsiderate psychologist who did our initial screen demanded payment up front, and wouldn't even give me the info I needed to fill out the paperwork for the insurance, so that was $1500 down the drain. The neuro and the PCP subsequently mentioned recommending the psychologist to other patients, and I recommended that they not.)
We had a PET scan two years ago. Strangely, BC/BS paid $2300 for the scan and later denied $350 for the radiologist who read the results. I think the problem is that his diagnosis was "Alzheimers" and they jumpted on that as investigative. I didn't want to bring to their attention that they had already paid so much for the test, so I just paid the doctor's bill. The latest twist is that the current neurologist says that it isn't AZ but is PPA probably caused by FTD or, specifically, Pick's Complex. So the PET scan really wasn't for the diagnosis of AZ.
my dh had a pet scan and the dr was suprised that the insurance approved it. i believe he had every other test they could possibly give him,so the insurance approved the pet scan. i think the insurance companies deny the claims because it is already obvious that the patient has ad or something similar, and the pet scans are so expensive, they just do not want to pay for another test when most of the time the drs pretty well think it is ad. jav
The insurance is different in every state and what is paid in one state may be considered experimental in another state. we were fortunate that my husband's pet scan was paid. Each state is different on most testing, so always get pre-approval if possible, or at least make certain that that procedure is covered (except for deductible and co-pay) and write down who you talked to and date and time.
For those of you who had the procedure denied, I hope you wrote in and requested an appeal of their decision. It has only been recently that the PET scan has been covered.