Insurance won't pay for PET CT

[AJ1234]

I was diagnosed with papillary carcinoma in Feb. 2010 and had a total thyroidectomy.  I had RAI in March 2010 and my 6 month whole body scan in Sept. showed activity in my left neck/cheek.  My endo wasn't sure if it was my salivary gland (I had a late side effect of the RAI; lots of pain and swelling when I ate) so she ordered a PET CT.  It lit up on my left side as well so she scheduled me for another round of RAI.  I went off Synthroid and started to prepare for it, but was still nervous about another round.  I talked to the oncologist I saw immediately after being diagnosed.  He compared my WBS and PET CT and noticed that the two areas that lit up were entirely different.  The WBS area was in my left cheek and the PET CT was in the lower left area of my neck, near the suprasternal notch.  The cheek area didn't light up in the PET CT.  I went back to my endo, pointed this out and she gave me three options: 1. surgery to remove the questionable area 2. repeat RAI or 3. wait 60 days and do another PET CT.  I chose the last option mainly because it was the least invasive and also it was the cheapest.  

Fast forward to the repeat PET CT...I called the facility the day before to make sure all preauthorizations were in place since I was taking a day off work, it's an hour away, etc.  I really didn't want there to be any issues with insurance.  I was told that everything was set and they wouldn't have scheduled me if the requirements weren't in place.  Plus I had a excerpt from my policy that states once a PET CT is approved, basically you can continue to get them for the same condition.  So off I went and had the repeat PET CT on Jan. 18th.  Thankfully, it was normal.  What a relief it was to find out I didn't need another round of RAI so soon.

Here's my problem though...insurance denied the claim and the cost is approx. $7,500.00.  There was a misunderstanding with the provider and they didn't actually get the preauthorization like they told me they had.  At first they told me not to worry and that they don't go after the patient in these situations.  They've since backed off of that as I suspected they would.  The basis for the denial is that my thyroglobulin wasn't > 10 and there is no record of a negative WBS within 60 days of the scan.  Both of these points are correct.  My endo is currently trying to convince my insurance to pay but in the meantime I'm losing sleep.  

Anyone with personal experience or advice?  Sorry this is so long.  I'm obviously not a dr.  I try to watch out for myself as best as possible but in the end I rely on the experts.  Sometimes I just feel I don't have the strength to deal with this anymore.  

[AJ1234]

I know -  that's what I was thinking too.  It's actually quite shocking because these aren't cheap!  After talking to the provider it is evident that someone dropped the ball and/or didn't know what they were supposed to do.  I documented who I talked to and when so at least I have that.  I'm prepared to pay my portion after what insurance would have paid (approx. $2K), just not the whole thing.  We'll see how this plays out.  Thanks again.  

[goolarra]

I'm actually surprised that the facility would have done the procedure without prepayment if they weren't absolutely sure of insurance company approval.  I'm not saying it will be easy, but I really think you did your part and the parties who didn't should have to eat this one.  Best of luck...let me know how it gets resolved.

[AJ1234]

Thanks for your response and for giving me some confidence regarding the situation.  

Looking back I should have called my insurance company and asked them to let me know the PET CT was approved in writing before I had it.  I know that and always called to verify everything I had done last year.  Based on all the facts, what the facilty told me, all the other procedures I had in the last year that went smoothly, etc. I just didn't.  Who knows, if everyone would have done what they were supposed to I might not have been able to get the PET CT done had I known I would have had to cover it myself.  

[goolarra]

It's hard to say whose fault it is, but if I were you, I'd refuse to pay the bill and let the facility and the insurance company fight it out between themselves.  This is not something YOU could have controlled, nor is it your responsibility to make sure everyone has done their job correctly.