While any insurance denial can be devastating to your treatment plan and your long-term health, a PET scan insurance denial can be particularly damaging. PET (positron emission tomography) scans use radioactive material to create an image that allows a doctor to find cancerous tumors, determine how well a specific cancer is responding to treatment, or diagnose heart disease, brain disorders, and many other serious diseases including Alzheimer’s disease.
A small amount of short-acting radioactive liquid (tracer) is injected into the person receiving the PET scan, then after about 90 minutes of resting quietly, the individual will receive a full-body scan, which typically takes about 20 minutes. Since cancer cells have a higher metabolic rate than typical cells, they will show up as bright spots on the PET scan.
A PET scan denied by insurance may state that there are not enough medical studies showing the PET scan is better than other tests like a much less expensive CT scan. This is simply not true. While a CT scan shows detailed pictures of an individual’s organs and tissues, a PET scan is much more sensitive, and can find abnormal activity and show changes in your body much sooner than any other type of scan, including CT scans and MRIs.
Why Could PET Scans Be Denied by Insurance?
As with most insurance denials, a PET scan is often denied by insurance due to cost. A CT scan costs approximately $600-$1,000, although more extensive CT scans can cost much more. A PET scan can cost anywhere from $1,200 to as much as $20,000. Because there is such a disparity in cost, most insurance companies will push for a CT scan rather than a PET scan. Unfortunately, a CT scan may not give your doctor the information he or she needs to properly diagnose and/or treat your health condition, so a denial can be extremely damaging.
What Should You Do if Your PET Scan Claim Is Denied?
The primary advantage of having a PET scan over a CT scan is that a PET scan exposes metabolic changes at the cellular level of the body, making it more likely that a developing disease can be detected at an early stage. If your doctor has ordered a PET scan that was then denied by your insurance company, you do have options. You may decide to first re-submit your claim with a copy of the denial letter and an explanation letter from your doctor that details why the PET scan is important for your health.
If this does not result in a reversal of the denial, you can formally file an internal appeal in writing. If an internal appeal is not successful, it may be time to consider legal action. An experienced insurance denial attorney from the Law Offices of Scott Glovsky can help you file an external appeal or, depending on your particular circumstances, may recommend you pursue a different path. If your external appeal is denied, attorney Scott Glovsky may take appropriate legal action to force your insurer to cover the costs of your PET scan.
Which Insurance Companies Are Known to Deny PET Scans?
While any insurer can deny a claim for a PET scan, some are more likely to do so. According to a 2021 Journal of Nuclear Medicine article, major insurers like Anthem Blue Cross, United Healthcare, Cigna, and Aetna repeatedly denied “clinically indicated PET imaging” to as many as 60 percent of their patients with prostate cancer. Blue Shield, Health Net, Kaiser, and others may also deny your doctor’s PET scan order. Since a PET scan can potentially determine how far cancer has spread, or whether a cancer treatment is working, it’s important that you not give up if your PET scan is denied by insurance.
How Common Is It for a PET Scan to be Denied by Insurance?
While there are no widespread statistics regarding how often PET scans are denied, the American College of Radiology expressed concern in 2021 regarding a decision by Humana to deny coverage of PET scans. PET scans were being denied based on an assessment that they were “experimental/investigational,” and “not identified as widely used.” The ACR said Humana’s decision denied patients access to “standard of care testing that is required to make lifesaving clinical decisions.”
How Can Your Doctor Help If Your Insurer Denies Your PET Scan?
For a PET scan denied by insurance, your doctor may well be your first line of defense. Not only can your doctor write a letter detailing why the PET scan is necessary, but he or she may also request to speak to the medical reviewer of your insurance plan as part of a “peer-to-peer insurance review.” This could help meet the guidelines for your insurer and prove that your PET scan was incorrectly rejected.
How the Law Offices of Scott Glovsky Can Help Following a PET Scan Denied by Insurance
A PET scan denied by insurance can feel like a very distressing blow at a time when you are already concerned about your health. This is a time when you need a strong advocate in your corner—someone who knows every tactic used by insurers to deny health insurance claims—and how to counter those tactics. Attorney Scott Glovsky routinely—and successfully—goes up against big insurance companies, making a positive difference in the lives of Californians. Once you contact the Law Offices of Scott Glovsky, you are no longer alone in your fight. Having a highly experienced attorney who will fight for justice with all his heart and soul can be the catalyst that turns your denial around. Contact the Law Offices of Scott Glovsky today.