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      How many of you are struggling to get PET/CT scans paid for?


        Surprisingly, we have not had recent difficulties getting PET/CT scans paid for in our melanoma population. However, I worry that some of our patients have a large copay for these scans. Yesterday, I had a Stage III high risk patient miss his appt; when I called him, I learned he also missed his PET/CT because of the high copay for the scan. We often interchange PET/CT with torso CT unless the area of concern is on an extremity.


        We have had this issue over the last several years. Medicare changed their policy to allow only 4 PETCT scans for a lifetime for a diagnosis. Many of the private payers have followed and only are allowing PETCT scans at initial diagnosis and/or if something it seen with what they determine as conventional imaging. We have found this most difficult in our patients who have subcutaneous or intransit disease for standard imaging doesn’t give us a good representation of their disease status.


          We are ordering less and less PET-CTs due to having to sell your 1st child to get insurance approve. However, in some cases, even for just CTs, I am finding more and more scan approvals require peer-to-peer discussions. These take up so much time, and must be done by APRNs or MDs.


          Our institution has transitioned to utilizing a radiology authorization team. This is a team of non clinicians interpreting and providing clinical information can sometimes trigger a delay in a review or result in a peer to peer. Overall the team is pretty good and this service has been helpful to alleviate some work load from our secretaries. The only pitfall is when they have multiple auths to that require peer to peer and we as the clinicians are only provided with a short window of time to obtain this.

          Most of the pvt payor companies we deal with have transitioned to a scheduled peer to peer appointment call. The negatives are that at times when an urgent auth is needed and no MD is available this can delay care rendered to the pt.
          Positives: you can (most of the time) choose the time when you would like to conduct the call, you can plan and prepare for it rather than having a reactive call with a scheduler/ secty calling asking you to get on the phone with the doctor who is on the line at that moment. I find the docotor is prepared for the call and that has contributed to a quicker and more often pleasant call.
          At times when I really need an auth before the next day, I have been successful with speaking to an MD within a short time frame or scheduled for later in the day/ just after clinic hours.

          Indeed though this is just one example of the numerous areas of a patients care that requires review and authorization.


            I can only ditto what others have said.
            We, too, have a centralized radiology pre-cert team, made up of non-clinical staff. They submit the initial request for prior authorization, along with labs/path/most recent progress note. When it still requires a peer to peer discussion (with the MD/NP/PA), we receive these requests very close to the time of the scan. Since these discussions now have to be “scheduled”, it is more and more challenging to have them completed prior to the original scheduled time of the scan and these often have to be rescheduled, along with the patient’s office visit.
            PET/CTs have become almost impossible to get approved other than at the time of initial diagnosis or as a follow up to equivocal findings on “standard” imaging. We have updated our clinical pathways to reflect this restriction and utilize CT c/a/p +/- neck or extremity for surveillance imaging in NED patients and for monitoring response to therapy in other patients.


              In the time from my last reply to now….I too learned there will be no more “on the fly” peer-to-peers. It is a scheduled call.

              One more thing…I have learned from speaking to many physician reviewers, the majority of the time, they are not oncologists! Often they are internists, or other specialty MDs, that just sit with guidelines in front of them- and that is how decisions are made. I understand the rationale by ensuring tests are indeed medically necessary and to be economically prudent, but as we all know….melanoma does not like to play by the rules, and often certain situations require certain specialty radiologic imaging. Decisions made by non-oncology physician providers are not always in the best interest of the patients (at least this is my experience…at times, now always).


                We’re having a harder and harder time getting them paid for. We do have a nonclinical precert team as well, which is helpful. However, I notice that sometimes they don’t include pertinent terms such as metastatic, etc. when submitting requests.

                I’m losing my mind with the fact that I can’t call and do a peer-to-peer at my convenience anymore and instead have to schedule them. It’s MADDENING! We’re busy enough, and anytime I have one scheduled, I inevitably have something come up in clinic and miss them. It’s even more frustrating when I learn about the peer-to-peer the day or two prior.

                I agree with Krista that many of physician reviewers are not oncologists, which further complicates the issue. INSURANCE!!!

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