Tag: 68Ga-PSMA-11

Day 4,037 – Insurance Rationale

On By DanIn imaging, Prostate Cancer1 Comment

Over the weekend, I received a letter from my health insurance company explaining the denial of covering the cost of the PSMA PET scan. This differs from what the representative told me via email (UCLA didn’t send all of the necessary paperwork) and carries far more weight, as it appears that a medical review was done. The redacted section below is the name of my insurance provider.

In a nutshell, because my PSA is 0.22 ng/ml, it doesn’t reach their threshold of 1.0 ng/ml, they deem the scan “not medically necessary” and won’t cover the cost.

The insurance company may have a limited point in their comment, “Use of this study would [not] improve the outcome” with my PSA level being so low. Realistically, the chances of the cancer metastasizing while waiting for the PSA to go from 0.22 to 1.0 are miniscule—especially with my PSA doubling time—and the treatment options would likely be the same: Salvage radiation, perhaps with hormone therapy as well.

However, the insurance company is missing the larger point: The whole purpose of having highly sensitive, highly specific scans like 68-Ga PSMA PET is to locate cancer early so that you can come up with an effective treatment plan that hopefully does, in fact, have a positive impact on the outcome and survival.

My urologists were supportive of getting the scan, so I’ll see if I can’t get them to help convince my insurance company through a formal appeal that this is, in fact, medically necessary.

As far as the scan itself, it’s less than 24 hours away. UCLA Department of Nuclear Medicine did remind me that I have to fast for at least six hours prior to the scan, drinking only water. No juice, no coffee, just water.

I’ll let you know how it went.

Be well!

Day 4,034 – Insurance Challenges

On By DanIn imaging, Prostate Cancer2 Comments

The administrative challenges continue…

On Tuesday, UCLA called to confirm my PSMA PET scan next week and, during the call, the said that they had not yet heard from my health insurance company as to whether or not they would cover the cost of the scan. She asked if I wanted to proceed next week, paying the $3,300 myself, or delay until the insurance was settled. If I delayed, the next available appointment would be in February 2022.

I told her to keep next week’s appointment and that I would battle it out with the insurance company after the fact.

On Wednesday, UCLA calls saying that my insurance had denied the request for the scan and wouldn’t cover the cost. Again, I reiterated that I would keep the appointment and pay the cost myself.

But I was curious about the reason for my denial, as I had an email from my health insurance company earlier in the year indicating the values that they would pay for each of the CPT codes that were given for the scan, so I emailed them again (after trying to get through on the phone on the day before Thanksgiving failed).

I was actually surprised that I received a response this morning that read:

I accessed your account and I see that the pre-approval was denied because of insufficient medical records was [sic] provided from the provider. I request you to please ask the provider to call…and verify the documents needed to submit for prior authorization then send the documents so that we can approve it.

Of course, UCLA is closed for the holiday weekend today, and I’ll have to just try to get them to get this taken care of on Monday when I go up there.

It’s always something.

Be well.

Month 131 – Biding Time

On By DanIn imaging, Prostate CancerLeave a comment

There’s really not much to report this month other that I’m simply biding time until the PSMA PET scan at UCLA on 30 November 2021.

I did receive confirmation that the doctor put in the order for the basic metabolic panel test and another PSA test, so I may get those knocked out this week to make sure they go well. I have to bring a hardcopy print out of the BMP test results to the scan, so better to get it done early to make sure that I can have a copy made available. If I can’t print it out on my own, then I’ll ask for it to be available during my appointment with the doctor on 9 November. (That was my next regularly scheduled appointment. I had hoped we would be discussing the PSMA PET scan results by then, but that’s not meant to be.)

Work will be keeping me extraordinarily busy through mid-December so, in a way, that’s a plus. It should keep my mind off of all of this. I just need to make sure that work takes a back seat to any appointments or tests.

On an unrelated note, I was able to get my seasonal flu shot and my Pfizer COVID-19 booster shot last week. I did take them together and felt a little wonky for about 36 hours (fatigued, felt as though I had a temperature but didn’t). Who knows whether it was the flu shot or the booster that caused that (or both), but it really doesn’t matter. I’m better and I’m better protected.

So that’s about it for this post. More to come…

Be well!

Day 3,968 – Logjam Broken?

On By DanIn imaging, Prostate Cancer3 Comments

The administrative logjam between VA Medical Center San Diego and UCLA may have been broken this morning.

Yesterday, I called UCLA to see if they could access my health record through the Veterans Health Information Exchange, and the short answer was “no.” While I had them on the phone, I asked if they would accept printouts of my medical records from me and, again, the short answer was “no.” They had to come from the doctor’s office. Ugh.

Not being one to always listen to what I’m told, I went ahead and sent my demographics and insurance information to UCLA on my own. I also hopped onto the VA website and submitted my official Request for Authorization to Release Health Information form so they could send my medical records to UCLA.

Within about an hour and a half of submitting the request, I had a call from the woman processing it. She had a couple of questions that I answered. “Great. I’ll fax this to them right now.” That was not the response I was expecting. I thought the VA would take 3-5 business days to pull the records and send them.

When I spoke with UCLA on Monday, they did mention how slammed they are with requests for PSMA PET scans, and that it may take a few days to process the paperwork on their end once it was received. I’ll give a call on Thursday or Friday to follow up and see if they have everything they need. With luck, they will and we’ll be able to get the scan on the calendar.

The scheduler said they were currently scheduling for late November right now.

Fingers crossed that everything will be in order and I’ll be able to get a scan on the calendar.

More to come…

Be well!

Day 3,941 – VA and UCLA

On By DanIn imaging, Prostate Cancer2 Comments

Progress. Slow, steady progress.

I received an email today confirming that the urologist had received, completed, and returned the referral form back to UCLA. They asked me to follow up with UCLA Department of Nuclear Medicine to confirm they received it. Gladly.

I called their scheduling office this afternoon to do just that but, unfortunately, my referral wasn’t in the system yet. I checked the time on the email I received, and it was only about two hours before I called UCLA, so that kind of makes sense. She said that it can take 24 to 48 hours to get the referral into the system.

The scheduler said that they’d review the referral, place the order for the 68Ga-PSMA-11 PET scan, and then call to schedule it. Right now, they’re scheduling in late October unless there’s a cancellation that I might be able to take advantage of.

On the one hand, I’m perfectly fine taking the ignorance-is-bliss mode of not rushing to this (considering my long PSA doubling time); but on the other, I want to get this going and find out what the next step will be. Right now, the primary thing on my mind is planning my next vacation.

I’ll call again on Friday to see if my referral landed in the system, and we’ll go from there.

That’s the latest in this odyssey.

Be well!

Day 3,939 – UCLA Referral Update 2

On By DanIn imaging, Prostate Cancer4 Comments

Just a quick update to yesterday’s post…

I called the UCLA scheduling office and explained the situation to the scheduler, and she thought that it was odd that the referral form wasn’t sent to my urologist for the referral. In any case, it took a whopping 5 minutes and 54 seconds—including navigating the phone menu tree, waiting for “the next available operator,” and the discussion—to hopefully break the logjam.

I called the doctor’s office and emailed him to let him know that he should be on the lookout for the faxed referral form. We’ll see what happens next—and when.

Be well!

Day 3,938 – UCLA Referral Update

On By DanIn imaging, Prostate CancerLeave a comment

I grew a little impatient with my team at the San Diego VA Medical Center not providing any information about the referral for the PSMA PET scan at UCLA since our consult on 3 August, so I sent them an email at the end of the week asking for an update.

This morning, the doctor that I had for the consult—the one who thought this was a good idea and who seemed eager to get it scheduled—reported that UCLA has yet to send him the form that he needs to do the referral. He didn’t exactly say when it was that he asked, but he did say that he would follow up with them tomorrow.

He gave me their fax number, so I, too, will give UCLA’s Department of Nuclear Medicine a call tomorrow to see what needs to be done to get them off the dime and to send the referral form.

That’s about it for now. More to come, I’m sure.

On an unrelated note, my bonkers incontinence issues have calmed considerably, but not quite back to where I can go without pads yet. Not sure what that was all about.

Be well!

Watch: Current Status of PSMA Diagnostics

On By DanIn imaging, Prostate Cancer3 Comments

Here’s a good overview of PSMA diagnostics by Dr. Calais, one of the UCLA doctors involved with getting 68Ga-PSMA-11 PET approved by the FDA. It’s a bit on the technical side, but it does show the strengths and limitations of the imaging technique.

Day 3,906 – UCLA PSMA Update

On By DanIn imaging, Prostate CancerLeave a comment

It’s been a week since I submitted the form on the UCLA website for a referral for the PSMA PET scan, and I hadn’t heard anything back, so I called them this morning.

When I mentioned that I submitted the form about a week ago, the agent said, “Oh. Yeah. We can’t book appointments using the form on our website. We need to take that down.” Uh. Okay. Good to know.

To schedule the PSMA scan:

  • The referring physician needs to call the scheduling number: +1 310-794-1005.
  • UCLA Nuclear Medicine will fax a referral form to the doctor to complete and return.
  • It will take 24-48 hours to process the returned form.
  • They’ll work with the patient to select a date for the scan.

They are currently scheduling appointments in September, so there’s a bit of a delay which isn’t all that surprising.

Now all I have to do is convince my doctor at the VA to go through the process once we get the bone scan results back. I’m not sure how that will go, but you can bet I’ll push pretty hard to make it happen.

If they insist on doing the Axumin scan at the VA first, I guess I’m okay with that. But if that comes back negative, I’ll really press for the PSMA PET scan. I’m just not all that keen on having all this radioactive juice injected in me over the course of a few weeks.

We’ll see how things go.

Be well!

Day 3,895 – Insurance Update

On By DanIn Prostate Cancer, Recurrence, TreatmentLeave a comment

I just received a quick update from my health insurance company regarding coverage of the Ga68 PSMA PET scan at UCLA—the quick turnaround surprised me. It appears to be good news, but it was a little squishy, so I had to ask for confirmation of a few things.

In their email to me, they listed the contractual amount that they would pay out for each CPT code that I gave them, but that’s all they said. It sort of implies that I’m covered, but it doesn’t say so explicitly. Needless to say, when dealing with insurance companies, I want things to be very explicit without any loopholes.

I just sent them and email asking them to:

  • Confirm that I am covered under my employer-provided healthcare plan.
  • Confirm whether or not UCLA Department of Nuclear Medicine is considered to be in-network or out-of-network (different deductibles).

Hopefully, I get that confirmation early next week and can share the information with my doctor.

More to come…

Be well!