CA125 covered by insurance?

[debyc]

I was diagnosed with a complex ovarian cyst in May and was sent by my doctor for a CA125 as a first step.  I needed surgery to have ovary removed and thank God cyst was benign.  I then submitted the bill for the blood test ($250.00)to my insurance company and payment was declined because I did not have ovarian cancer.  They tell me it is only covered if cancer was diagnosed.  One one hand I am relieved I do not have cancer, but on the other, I am angry that this blood test is not covered.  Anyone have similar experience?

[beyondthesea]

Hi! This is a tough one....I was also diagnosed by transvaginal ultrasound to have a complex cyst back in July. I was sent for a CA125, and the girl at the lab told me up front that my insurance company would NOT cover this test. I even had to sign a form stating that I understood that this would be a self pay thing. I think it was only going to be around $80, NOT $250 though! Anyway, of all things, my insurance covered the whole thing! The only difference I can think of is that my mom had just been diagnosed with OVCA a month earlier, so maybe having a cyst PLUS the family history made a difference????? Did you call your insurance company for some clarification?

Just curious, and a bit off your original topic, but did you end up just having the one ovary removed, or everything? I'm in the same situation, and trying to decide whether to only take out the one ovary, or to go with a full TAH/BSO since my mom has OVCA. My doctor will support either decision. My surgery is Sept 19, so I need to decide quick! Nothing like a little pressure, huh?

[kathy o]

Ridiculos!!!  The ca125 is not an Ovarian Cancer Test only, as a matter of fact it is not a reliable test for OVCA at all, only in some cases. Furthermore this test only cost 44 dollars where I live, (WA State). Sounds strange to me!!  Good Luck! Glad that you did not have OVCA!
Kathy

[gah_70]

I suppose it's all said and done now, but in a case like that, I would contact my insurance liason.  I work for a company with 13,000 employees, so we have a person who's job is only to be the "go-between" between employees and our insurance carrier.  But, in your case, it may be someone as simple as an HR rep.  Anyway, Kathy is right...the CA125 will not diagnose OvCa, but it IS a starting point.  Maybe your insurance carrier sees it as wasteful since the results are not definitive.  But if it is high, a doctor will use it to investigate further.  For that reason, it is an important tool.  I don't know why an insurance carrier would refuse to pay for something that in the long-run, could save them more through early detection.  Hmmmm.  

I, too, am happy for your results, though.  I hope you are healing well and on the path to feeling better than ever!

Gail

[debyc]

I only had my left ovary removed since the cyst completely engulfed (sp?) it.  My right ovary looked completely normal although according to my obgyn it is starting to dry up (ah the joys of getting older!).

[in the same boat]

Regarding your insurance denial for the CA125.  It's possible it got denied by the way they billed it. Claims are processed according to diagnosis code that is submitted with it. If they billed it with a "routine diagnosis" that could be why it was denied. You may want to contact the LAB billing dept & ask what dx was submitted. Sometimes they will bill with a "V" code which is routine. Sounds like they should have billed it with an "ovarian cyst" diagnosis code which might make a difference. Also check the wording in your Plan Booklet & look up the CA125 test under "covered benefits"  & then again under "exclusions & limitations". If it says in there SPECIFICALLY that you have to have cancer to have this test,then you might be out of luck. If NOT then you might be able to appeal the claim to have it covered. Hope this helps.