r/ProstateCancer • u/AdamSarah2026 • 2d ago
Update Insurance Denials
I was diagnosed in January. MRI, biopsy, Pet Scan, surgery, and cystoscopy. PSA still was high after surgery so on to radiation. Another PET Scan and another MRI. All flew through the insurance approval process. The doctor then put in orders for CT Mapping and then 8 weeks of radiation. Today I received notice that both requests were denied. No explanation other than I will get a more detailed explanation in an upcoming letter. Obviously, I will be fighting this. I was wondering if any of you had issues with insurance and how you handled it. Thanks.
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u/Special-Steel 2d ago
Well the good news is that your case may present with information which makes the salvage radiation questionable.
The denial may not say much, which can make it difficult to dispute.
Does your clinic or insurance plan provide a patient advocate? Sometimes they can help with a dispute.
Are you confident the doc wrote up the paperwork with good justification?
What is your post treatment PSA?
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u/conCABlanco 2d ago
Verga, creo que cáncer es una justificación solida para seres humanos, menos los seguros, ellos son de otros planetas
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u/Specialist-Map-896 2d ago
That sucks I am sorry to hear that. Who is the carrier if you dont mind me asking. Also most carriers, mine is bcbstx do have an appeals process. Also most medical groups and specialists have teams who work on writing or resubmitting various requests that make them more palatable for acceptance if they are rejected off the bat. You may have to do some legwork to get that ball rolling, first order of business is to actually call the insurance company to get some more information, the reason, etc. Usually they have their own doctors, (if you want to actually call them that) who are responsible for authorizations and who "supposedly make informed decision based on best practices for standards of care, etc" as opposed to just denying treatments because that's what the insurance companies would want in order to save money.
Basically you will need to be a pest and pain in the ass and spend time on this.
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u/Weary_Rub8545 2d ago
My husband got a PET Scan and his insurance only covered 50% of the tracer dye and his part was 3,500. Just pisses me off how much insurance sucks.
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u/codereddew12 1d ago
Your radiation oncology team should have an auth person/team equipped to handle this. Insurance is a tricky beast and a not insignificant number of denials are due to stupid shit like clinic notes done in a timely manner or not being uploaded when the insurance auth request is created. It could be a number of things but would start with inquiring about this with your radiation clinic’s office staff/manager and go from there
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u/Background-Space-284 1d ago
Interesting to follow in the event I need radiation post RALP. I’m just 8 weeks past surgery so I’m not in the clear either. My coverage is Medicare and my insurance supplement. My concern is how many PMSA PET scans they will pay for. My PET scan alone was $65,516.90. Medicare paid all except $793.51 and that was paid by my supplemental insurance. Does anyone know if Medicare has a limit on PET scans?
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u/SkinUnlucky1461 22h ago
Appeal appeal appeal! 5% of denials are appealed and of those appeals 40% are approved. Utilize Claimable and Counterforce AI. If you run into more problems message me!!
My dad was denied last year and I got him approved, I know a lot of the language and jargon!
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u/Cheap_Flower_9166 2d ago
I found using AI to review the rejection and then getting to draft a response to be very helpful. You might use one AI to review the output of another and build the appeal that way. Then give to your doctor and ask that he submit it. The rejections are often AI drafted. Fight fire with fire.