Curious if anyone has had difficulty getting CIGNA, when on a PPO, to cover PET scans when for either maintenance check-ups--i.e. periodic testing every 6 or 12 months when in remission OR when disease is active?
My situation is they are denying coverage saying is it not medically necessary and trying to stick me with the $3800 charge.
wondering if anyone out there has any strategy they have used or story about how they were successful in arguing with CIGNA to get them to cover the Pet scan.
They use a 3rd party outsource company called Medsolutions that makes their coverage determinations. what really irks me is that some "doctor" that has never met me and does not really know the case history makes the determination. Even after a consult with my doctor, one of the leading myeloma practitioners in the US, they still denied it.
I have heard from the medical facility that asking for the medical background of the 3rd party doctor and their medical license number and showing you are not going to back down can sometimes carry the day and get them to cede.
Looper, I can't speak to your situation specifically, but I can tell you that the brief time when my husband and I were covered by Cigna was a time when anything and everything was denied coverage. Their policy seems to be: deny, unless the insured makes a really big fuss. I breathed a sigh of relief when my husband's company changed insurers. Definitely, don't back down.
I am an RN Case Manager with A different large company. Each plan may have their own guidelines regarding PET scans. Ours states that PET is appropriate for initial staging, rest aging, every 3-12 months up to 5 years, when clinically indicated…so basically- it’s appropriate. The ultimate guidelines that every provider, physician, treatment center has to follow comes from the NCCN guidelines, which detailed clinically appropriate surveillance, treatment etc for every type of cancer. If the NCCN guidelines are not followed, then it is considered “experimental or investigational”, that is where trials come in. SO, the NCCN guidelines state that PET scans ARE appropriate in MM, SMM and MGUS. Appeal the denial. Chances are that someone with no medical background or the computer automatically denied it. Demand a case manager with Cigna follow him long term, they will review his requests. Demand an “expedited appeal” and have his heme/onc nurse help you. Good luck,
Julie
I went and found the NCCN guidelines---seeks pretty clearcut to me, especially as to how they could possibly second guess my physician's decision. Now I wil compare that vs. the protocols they are claiming they are using. This info is incredibly helpful---thank you SO much. Off to start writing the appeal---nothing like having to worry about defending one's bank account as well as one's health.
Jules said:
I am an RN Case Manager with A different large company. Each plan may have their own guidelines regarding PET scans. Ours states that PET is appropriate for initial staging, rest aging, every 3-12 months up to 5 years, when clinically indicated....so basically- it's appropriate. The ultimate guidelines that every provider, physician, treatment center has to follow comes from the NCCN guidelines, which detailed clinically appropriate surveillance, treatment etc for every type of cancer. If the NCCN guidelines are not followed, then it is considered "experimental or investigational", that is where trials come in. SO, the NCCN guidelines state that PET scans ARE appropriate in MM, SMM and MGUS. Appeal the denial. Chances are that someone with no medical background or the computer automatically denied it. Demand a case manager with Cigna follow him long term, they will review his requests. Demand an "expedited appeal" and have his heme/onc nurse help you. Good luck, Julie
Thanks for your thoughts. Yes, over the years we moved form Cigna to Blue Cross but then my company dropped them and now my only choice is Cigna again. Blue Cross was great---never second guessed anything like this.
dancermom said:
Looper, I can't speak to your situation specifically, but I can tell you that the brief time when my husband and I were covered by Cigna was a time when anything and everything was denied coverage. Their policy seems to be: deny, unless the insured makes a really big fuss. I breathed a sigh of relief when my husband's company changed insurers. Definitely, don't back down.
I just realized that I have accidentally stumbled across Cignas internal criteria in the past. I will do some digging to see if I can find heir MM PET criteria. Did you get a denial latter? Do you have a phone number for their appeal department? I always tell people to call the insurance appeal department and tell them that you want to appeal, that gets the clock ticking.
Got word of need for testing on a Wednesday for tests to occur following Monday.
UAMS reached out to get pre-certification immediately.
Heard back late on that Friday that the PET and the MRI's of the head and bone marrow and sternum were being denied
My MM doc had a peer to peer with the MEdsolutions "doc" but still was rejected---this occurred before the testing occurred
Unsure as to how they can deny other than the fact that Medsolutions has no factual background on me. This is pretty clear-cut, given this is a relapse situation and when initially diagnosed in 2005 I had lesions, modeling etc in skull, ribs and on my most recent MRI of the serum there was even a lesion then. Kind of hard for them to argue lack of medical necessity when my doc knows the whole history and they don't.
I went ahead and had the tests cause they were necessary so now we are appealing. Going to have to do the same thing again in May when I have to go back for more of the same tests.
I have read their protocols which they attached to the denial letter which seem to indicate that for re-staging they will cover PETs and MRIs for areas of previous involvement but initially back in 2005 I was at 80% cellularity so pretty much every area was involved. If I was a lawyer I would say they have weak ground to stand on.
I have been assigned a case manager at Cigna but frankly don't trust the organization and am fearful any info I give her may somehow be turned against me from an appeal perspective.
Jules said:
I just realized that I have accidentally stumbled across Cignas internal criteria in the past. I will do some digging to see if I can find heir MM PET criteria. Did you get a denial latter? Do you have a phone number for their appeal department? I always tell people to call the insurance appeal department and tell them that you want to appeal, that gets the clock ticking.
I was at UAMS just this past weekend for my son's AVM checkup, Looper, and I noticed the signs for the Myeloma clinic. I was glad there is a clinic at UAMS, because I think it is a terrific hospital. I hope this appeal goes through swiftly so you can get the tests that you need!
You have the right to ask for a medical director with a like specialty to review your appeal, otherwise it could be reviewed by a family practice doc. Ask for a heme/onc that specializes in MM, and ask for a peer to peer, he will speak to your doctor. UAMS is a large teaching hospital, my doc came from there. The large teaching hospitals pay for testing that insurance doesn’t cover. My doc told me they will always cover it, they get to use my results in his studies. I haven’t heard bad things about Cigna, I have some friends that work for them. The lymphoma leukemia association pays for things that insurance doesn’t. Let me know if you want me to send you any info.
Let me know how it goes.
Julie
interestingly UAMS is the world's largest facility for MM...the doctor there back in the 1980's was at MD anderson and couldn't win the political battle to get his own MM clinic there at MD because it was already such a renowned cancer institute---so many other bigwigs clamoring for funds-----but just so happened he had a myeloma patient at the time named Sam Walton---who said well, if you want your own clinic I think I can help you with that----$300 million endowment later and poof he was on his way.
dancermom said:
I was at UAMS just this past weekend for my son's AVM checkup, Looper, and I noticed the signs for the Myeloma clinic. I was glad there is a clinic at UAMS, because I think it is a terrific hospital. I hope this appeal goes through swiftly so you can get the tests that you need!
I will do so--let me digest this and talk with some more folks and begin to crafty my appeal etc and then I will reach out if more info would help. Thanks so much for all your thoughts.---no doubt it is this type of thing the forum is to help us all with.
Jules said:
You have the right to ask for a medical director with a like specialty to review your appeal, otherwise it could be reviewed by a family practice doc. Ask for a heme/onc that specializes in MM, and ask for a peer to peer, he will speak to your doctor. UAMS is a large teaching hospital, my doc came from there. The large teaching hospitals pay for testing that insurance doesn't cover. My doc told me they will always cover it, they get to use my results in his studies. I haven't heard bad things about Cigna, I have some friends that work for them. The lymphoma leukemia association pays for things that insurance doesn't. Let me know if you want me to send you any info. Let me know how it goes. Julie