Insurance won't authorize PET scan

[abrite]

I was diagnosed 3C Sept. 2005. Finished primary chemo Oct. 2006. Recurrence July 2007 in 2 lymph nodes and lining of liver. The recurrence did not show up on CT scan but was found on PET scan and was suspected due to rising CA 125. Have been on chemo since July 2007. My CA 125 has been 12-18 for the last 5 months and my last 2 CT scans have shown no evidence of cancer. My gynonc is talking about taking me off of chemo. He ordered a PET/CT for March to make sure there is no undetected cancer. The insurance company has denied the PET scan but has authorized the CT scan. I am very frustrated.....any suggestions? Would those who pray please do so :-)

(Thanks JC 145 for suggesting I start a new thread....sometimes I am not too swift!)

[JC145]

The doctor cannot use the words "Rule Out ________" as in Rule Out lung cancer, or Rule Out Lymph Node Involvement.  This would be the third option listed above.

I would still try to contact the MD to speak with NIA doctor to doctor.

Judy

[bohan54]

Sorry, editing comment:  PET lights up areas ....

[bohan54]

Have not had a PET as yet.  Asked doc and clinical trial nurse.  They both believe in CT as it measures disease area more specifically.  Apparently it lights up areas that may not be cancerous so they do not routinely use it.  
Try not to sweat it, stress is always to be avoided!
Sharon

[abrite]

Thanks everyone for your suggestions. I just received the denial letter from NIA. I can appeal and have an answer within 30 days unless there is imminent danger to my health and then a response will be given within 72 hours. I was referred to http://www.radmd.com/misc_pages/clinical_guidelines.htm
for the following specifics about the authorization criteria for my insurance.

PET Applications:
•
Staging (Initial) – Vast majority of requests will fall here as initial staging to know after the cancer diagnosis was made if it is local or more spread mets.
•
Re-Staging – Use to evaluate after completion of treatment (only one test can be approved after treatment) or restaging if new signs or symptoms.
•
Surveillance – Obtaining a PET to just see what is happening is not covered. Patient must have a reason to obtain studies such as new signs or symptoms or follow up (restaging) after treatment.

[butterflytc]

This question was asked on the Doc's forum. I copied and pasted her response.
by Annekathryn Goodman, M.D.


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Annekathryn Goodman, M.D.  
Female, 49 years
Boston - MA
Member since Jun 2006  



, Jun 14, 2008 10:29AM
Dear Damon,

thank you for your question.
a PET scan is a nuclear medicine scan where a radio labeled sugar molecule (FDG) is intravenously given. Areas of active metabolism either because of infection or cancer will take up the sugar (called FDP avid on reports)

This FDG avidity combined with CT scan will pick up more areas of abnormalities.  However, CT scan alone is probably adequate especially in the setting of a normal CA 125.

So I might suggest reserving PET scan or PET-CT scan for situations of abnormal CA 125. This is a very expensive test and many insurance companies will not routinely approve it without indications.

best wishes

hope it helps
butterflytc

[Teresa222]

Thank you for the information.

I've not had this happen YET.  I really would like a PET scan when I finish Doxil. I have two more treatments.  Does anyone know how long it takes to submit the request to the insurance company and get a final "no?" (or yes, if we're fortunate)
Teresa

[JC145]

Your Onc should talk to the insurance company rep. who is making the decisions on PET scans.  This sometimes works.  MD's usually don't like to get involved, but will do so if pushed a little.

Good Luck,

Judy