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My husband's insurance will not pay for a PET Scan. They only pay for the one at time of diagnosis, and will not pay for monitoring during chemotherapy. He is due for another one in two weeks, and please, please - is there anything else that can be used as an equivalent for a PET Scan? A CAT Scan is not enough.
Thanks!
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Permalink Reply by Niti/MOD on Something is not right. Typically re-staging LC (meaning checking to see if chemo has worked) can be accomplished with a CAT scan. If, for some reason, your husband must have a PET scan, then you can appeal the insurance company's ruling. To my knowledge there is no test that is a PET scan equivalent. Anyone else have any better info?
Presumably your MD has declared the PET scan medically necessary, can and will explain why a CAT scan is insufficient and can explain that a PET scan to re-stage is not an experimental procedure. Usually all of this is enough to mount an appeal.
There should be a staff member in your oncologist's office who is familiar with the appeals process and can assist you in filing an appeal.
Good luck and please keep us posted.
Best,
Niti
Permalink Reply by littlelady4220 on He had the one scan in January 2011, that was a diagnostic tool and they paid for it. Then they did one in June and October 2011, they were denied and we are now stuck with thousands of dollars. The doctor wants to do another one in two weeks, we are very wary of it. First, for the problems with insurance, second for the constant exposure to radiation. We had appealed the two PET scans that were denied, and they came back with the final denial the other day. Legally, they are correct, because the policy states that a PET Scan will only be paid for diagnosis and not for monitoring or surveillance. That is why I wondered if there was something other then a PET Scan that could be used. This oncologist insists a CAT scan is not going to be sufficient.
Permalink Reply by Niti/MOD on I am going to ask someone at LCA for suggestions on how to help you. Stay tuned!
Niti
Permalink Reply by Sarge on Good idea Niti/MOD................also, if I may suggest...........I would also be actively seeking a second opinion from another oncologist. I did not have a second PET until 12 months out from last treatment (2.5 yrs. ago, and have not had another...........CAT scans have been the measuring tool since then, and this has been consensus of all my docs.
As much as we don't want to think about it, some docs have a motivation to see more expensive testing done, especially if they own a part of the diagnostics process as well as their practices.
Sarge..
Permalink Reply by AmyLCA on Hi littlelady,
If I understand correctly, your husband has recurrent metastatic small cell lung cancer. It was diagnosed in Jan, so that was the first staging PET. Then he had a PET in June, which I presume was when he finished treatment. Then in October when the recurrence was diagnosed. Those seem like reasonable timeframes, but obviously your husband's insurance plan won't cover it. So that's a challenge.
Did the oncologist say why he/she felt the CT would not be sufficient? I mean, if it's not an option, it's not an option and the doctor should explore other ways to monitor. Perhaps it would help to know what your husband's insurance does cover for monitoring and surveillance and go from there?
I know you already appealed the decision, but I am inclined to suggest pushing further with the help of a case worker from the Patient Advocate Foundation or the Cancer Legal Resource Center.
I think what folks are responding to here is that things are different for non-small cell lung cancer as far as monitoring. CT scan is the standard way to follow up in NSCLC, although it would be MRI for brain mets. CT will detect things outside of the lungs though, so I'm still not sure why that's not an option.
Sorry about these challenges!
Amy
Permalink Reply by littlelady4220 on You are completely on target. I did not know there were organizations such as these and I appreciate so much that you have given me their contact information.
The oncologist's office has tried everything, even to the point of recoding, but the policy clearly states, in writing, that PET Scans are covered only for initial diagnosis. From everything that everyone has written and said from so many sites, CAT Scans should be sufficient. However the oncologist feels they don't tell the whole story. And I'm not happy with the exposure to the radiation from PET's.
Thank you for the information!
Permalink Reply by AmyLCA on Oh this must be so frustrating. But my guess though is that the CAT scan will be able to tell much of what needs to be known. And I wouldn't worry about the radiation exposure - not to concern you but CAT scans have radiation too, but it's so much more important to know what's going on and be able to treat it. A few CAT or PET scans is not going to cause problems in the grand scheme of things.
Permalink Reply by littlelady4220 on
Now that my husband has had his PET Scan, here are the results - and some questions - again!
A brief history - he was dx 1/11 with SCLC-Extensive, went through six rounds of carbo/etop, had a PET Scan 6/11 and it showed of the six tumors, five were gone and one was streaky. Then he had another PET Scan 11/11, and it showed that the tumor came back in his liver. Did 3 rounds of Topotecan, just had another PET Scan, showed the tumor was the same. So now the onc is going to do 3 more rounds of Topotecan. Says that he won't use another chemo drug as he doesn't want to go through them all in case he needs them in the future.
So, my question is, how many chemo drugs can be used on SCLC and how many lines of chemo can be used?
Permalink Reply by AmyLCA on Hi littlelady,
Is the tumor in his liver the only one present? Might be worth asking his doctor about a procedure called Radiofrequency Ablation, or RFA. It is sometimes used to kill liver tumors.
Has your husband considered clinical trials if the toptecan doesn't work? If it has been over 6 months since the last time he had carbo/etoposide, his doctor might consider repeating that since he had a response to it last time, or doing cisplatin instead of carboplatin. There are other drugs approved for SCLC, but there are some interesting clinical trials going on too. Take a look here for info about clinical trials: http://www.lunglovelink.org/page/clinical-trials
For more in depth info, you can visit the LCA website to learn more about clinical trials by going here: http://www.lungcanceralliance.org/get-information/what-if-i-am-diag...
Amy
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