Problems with CT Scans

[ike1968]

Anyone had problems getting your insurance companies to pay for CT scans? I had an RPLND done in late August and my Dr. has requested a CT scan before my November appointment. Blue Cross Blue Shield just sent me a letter stating

"The history presented of testicular cancer does not demonstrate sufficient medical necessity to justify certification of this examination at this time. There is no evidence of further pertinet history, symptoms, physical findings on abdominal and pelvic examination, and recent imaging and laboratory test results, and treatment with response, that supports this requested examination."

Dan

[Scott]

Perhaps the note from page TEST-11 of the NCCN guidelines would help: "Patients status post RPLND, a postoperative baseline CT scan is recommended."

[Paul54]

The NCCN guideline TEST-11 also says that CT scans post-RPLND are every 6 months. If BCBS has that programmed into a screening program, they probably think your next scan shouldn't be until February. I hope a quick phone call will clear up the confusion over needing a post-op baseline scan.

[Scott]

Originally Posted by Paul54

The NCCN guideline TEST-11 also says that CT scans post-RPLND are every 6 months.

It actually says CT scans post-chemotherapy are every six months. The note says only a baseline CT scan is needed after RPLND.

[Paul54]

The title of the table says Surveillance After Complete Response to Chemo and/or RPLND. What I'm sayin' is that BCBS may not have gone any further when they programmed their screening tool, and that a call to them will hopefully clear up the denial about the baseline.

[Scott]

Originally Posted by Paul54

The title of the table says Surveillance After Complete Response to Chemo and/or RPLND.

If you're looking at version v.2.2009, there's a critical footnote: "CT scans apply only to patients treated with chemotherapy. Patients status post RPLND, a postoperative baseline CT scan is recommended." As a general rule, CT scans after RPLND aren't needed, because the odds of abdominal recurrence are so low. Chest x-rays are sufficient.

Originally Posted by Paul54

What I'm sayin' is that BCBS may not have gone any further when they programmed their screening tool, and that a call to them will hopefully clear up the denial about the baseline.

We're on the same page about appealing.

[ike1968]

Thanks guys... I'm going to call my Dr to see what he says. Original letter was sent to him. I got the cc over the weekend.

Dan