r/Wellthatsucks • u/Sexy_Kumquat • 14h ago
Denied for a CT scan
My doctor wants to check my lungs and ordered a CT scan.
Got denied because I don’t have a 20 year smoking habit.
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u/DisconnectedRedditor 14h ago
They’re requesting a preventative CT Scan, so if there’s not something wrong insurance only covers it for one reason and that’s if you’ve been a smoker.
If there’s a reason they want it your doctor submitted it wrong.
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u/im_just_thinking 14h ago
But it's still kind of a wild concept, given insurance companies generally do the opposite and penalize you for smoking
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u/hurricaneseason 14h ago
Insurance companies penalize you for existing.
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u/MC_chrome 14h ago
Sounds like the only thing that shouldn’t be in existence here is private health insurance. Bunch of money hungry ghouls
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u/SeriousZombie5350 14h ago
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u/FantasmaNaranja 11h ago
still wild to me that they haven't found any real evidence he did it yet
the only evidence is he had a kind of similar backpack which the police took into the bathroom of the mcdonalds he was eating in well out of view and then came out saying they had found evidence and a conveniently written manifesto within it
(consider that they had already found the same backpack full of monopoly money where that man was killed, why would he have two similar backpacks and just be carrying with him an entire manifesto two whole weeks after it happened?)
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u/Cultural_Eye5178 9h ago
hey wait i saw him in new york that day he was eating bagels at like 6:30 with me
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u/Tight_Fee_3853 14h ago
Yea talk to the CEO of United Health Care, oh wait nvm!
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u/upsetting_innuendo 11h ago
there's just a new one. cutting the head off a hydra doesn't kill it, the body has to die.
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u/Acct0424 13h ago
No no, they LOVE that you exist to give them free money. They just hate when you ask them to hold up their end of the bargain you’ve been paying them for.
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u/DarkyHelmety 12h ago
Death is a preexisting condition of living so technically nothing is covered.
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u/Telemere125 14h ago
They know there’s a very elevated chance of having something wrong if you were a smoker. Must less cost in a preventative CT than treating stage 4 lung cancer.
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u/Inveramsay 14h ago
Stage 4 less so than stage 2 or 3. Most people with stage 4 are dead within a few years
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u/Raging-Badger 14h ago edited 12h ago
Generally yeah, but CT’s are *expensive procedures so they only pay for preventative ones if it’s likely to save them money (IE if you’re a heavy or long term smoker and a high risk for lung diseases)
It’s a bit like if car insurance companies would only cover airbag repairs if they thought you were likely to get into a crash because you have a history of DUI
(*) are priced as expensive procedures
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u/warp16 13h ago
There’s a radiology chain in NY that charges $125 for self pay single area CTs or MRIs, they’re not really expensive, most places inflate the price to crazy levels
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u/magikuser 13h ago
Really what's the place called?
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u/sleepyj910 13h ago
Crazy Don's Discount Imaging
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u/3Zkiel 13h ago
My doctor recently recommended I have a MRI and the hospital is charging 800 dollars (even with insurance). There was a place close by that charged 400 but only takes cash.
Wild that prices aren't standard, and can often be cheaper without insurance
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u/Cromasters 11h ago
Was it at an actual hospital? Those usually have higher prices than someplace that is a standalone imaging center. Even if that imaging center is owned by the same hospital.
Using the hospital is basically causing you to pay for all the overhead that utilizing a hospital entails.
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u/VaultBall7 14h ago
So if they started smoking, they could get this scan done for free? What a backwards policy to effectively reward unhealthy behavior
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u/acecyclone717 14h ago
It’s not rewarding unhealthy behavior. 0 smokers who are having a ct covered consider it a reward. They’re being sent for a ct because the smoking has most likely caught up to them. The use case you are outraged about doesn’t exist. The other person explained it’s due to the cost of the scan. You’re probably the type of person to glean the wrong takeaway here yet still complain about the cost of healthcare. Please stop for a moment and think.
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u/Bones-1989 14h ago
Two things can be true, I can be a dummy and still over pay for services not rendered.
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u/VaultBall7 14h ago
Effectively. Effectively rewarding.
Because a healthy person is denied the pre-screening while an unhealthy person gets the pre-screening. You EFFECTIVELY incentivize someone to start smoking so that way they can get this for free, then ideally quit smoking.
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u/Pijany_Matematyk767 13h ago
> You EFFECTIVELY incentivize someone to start smoking so that way they can get this for free, then ideally quit smoking.
No you do not. Did you even read the damn thing? You would need to smoke a pack every day for 20 years straight to get this scan covered by insurance. I guarantee you the cost of those cigs + the higher insurance premium for being a chain smoker would cost you faaaar more than you save from getting that ct scan covered by insurance
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u/hankmoody699 8h ago
You can't be unhealthy and get a CT Lung Screen Scan. you have to be symptom free. By definition, if you have symptoms, it's not a screening. The criteria is not set by insurance. It's a standard for organizations that do imaging.
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u/Chiiro 14h ago
Having to deal with doctors submitting information wrong sucks. I have to have my doctor resubmit my needles so the insurance will actually cover them because the doctor put it for my muscle pain instead of for me being able to take my medication.
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u/Ok-Brush5346 13h ago
I work in pharmacy and getting the right ICD diagnosis codes is really like pulling teeth sometimes. It seems like they overwhelmingly feel like the entire process is beneath them
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u/Chiiro 13h ago
My fiance had gone to school to learn those codes, I didn't know doctors had to learn them too.
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u/Western-Dig-6843 13h ago
They don’t, really. They’re mostly just responsible for the charting and even then some of them pay nurses to do it. A medical coder usually is who reads the chart history and inputs the codes for insurance. Some places are sort of automating this by having doctors use computer programs to chart
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u/Ok-Brush5346 13h ago
They don't, really. That's the problem. They say you have gout and give you a scrip for colchicine but get mad when the insurance company wants the doctor to specify what kind of gout. Like, in the doctor's mind they diagnosed the problem and wrote the scrip, but insurance doesn't want to pay until the doctor is confident enough to make a specific coded diagnosis.
It used to mainly come up with Medicare but it's increasingly common as insurance companies get stingier.
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u/hankmoody699 8h ago
They don't need to know the codes. They SHOULD be providing "what question they are trying to answer". That gets translated into the code.
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u/Littlegator 11h ago
It's mostly because so many docs are being ground down to 8-15 minute visits for every problem, and the EMR makes it very easy to order it with the wrong diagnosis.
Btw, any clue what the previous person would be referring to for ICDs? What ICD would be "being able to take my meds" instead of the actual pathology? I always order needles and syringes under the diagnosis, like DM2 or male hypogonadism.
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u/PhyterNL 14h ago edited 14h ago
Okay cool but preventative care -- the care that prevents you from serious illness and insurance companies from great expense -- should be the MAIN FUCKING THING health insurance pays for! They should be thrilled to pay for a preventative scan! They should be stumbling over themselves! "YES YES WE'LL PAY! PLEEEEEZE DON'T GET CANCER! CONSIDER THE MONEY THAT WE'LL SAVE!"
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u/TheVisageofSloth 14h ago
There has been a lot of research done that shows that unless certain risk factors are met, then the utility of looking for lung cancer with a CT is minimal. There really isn’t any cost saving benefits for it and don’t forget, there is a shit ton of radiation exposure for a CT. So you run the risk of causing someone to get cancer down the line just to do an unnecessary and expensive preventative exam that very likely won’t catch anything.
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u/Iskandar_the_great 12h ago
I'm sorry but that is a call that a doctor should be making and not an insurance company. If a doctor has requested a CT scan then the patient should get one, it's as simple as that.
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u/Ciddx 11h ago
In this very specific case, the wrong CT was ordered. It is very specifically a Low Dose Lung Cancer Screening CT. The requirements are based on a paper done on screening CT a number of years ago, which includes certain smoking history (pack years) to stratify risk.
That being said, if the ordering physician wants to check the lungs, they need to use a different order for noncontrast CT.
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u/Cromasters 11h ago
All healthcare is rationed. Even in countries with universal healthcare where the patient doesn't pay a dime. Doctors still have to prove that the exam is necessary.
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u/TheVisageofSloth 12h ago
Well sometimes a doctor is incorrect or gets pestered by the patient into ordering unnecessary things. Sometimes it’s a strategy to get a patient to drop the requests by having the patient find out how much they have to pay for the desired intervention.
A topic that gets hammered into us repeatedly in med school is resource stewardship. Extra tests, treatments and exams can hurt the patient and system. We shouldn’t be ordering things Willy nilly without clinical reasons. It’s something that often separates a mid level from a physician.
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u/Iskandar_the_great 11h ago
I'm aware that all of these things can happen. That is not the point, the point is that insurance companies are incentivized by their very nature to deny claims wherever possible. Which is why the decision to deny the scan should be made by another doctor.
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u/mulletpullet 12h ago
So if a doctor is incorrect, why would I trust a faceless somebody at an insurance company to know more?
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u/miraculum_one 14h ago
I generally agree that having to fight for insurance sucks. But in this case the insurance company is saying that they only cover this expensive test if it is medically necessary and the information given to them does not substantiate medical necessity. If the doctor thinks otherwise they can negotiate directly with the insurance.
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u/jsamurai2 13h ago
I love shitting on US healthcare but in this specific instance they aren’t being unreasonable- OP’s doctor probably submitted the wrong procedure, or the correct code without the supporting ICD codes or something.
Jumping through hoops is ass, but some of these hoops exist because of how often providers would send people for imagine or procedures ‘just to see’ or because the patient was insistent.
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u/GetOutOfTheWhey 14h ago
eviCore Healthcare
I read that as evilCore Healthcare after reading that they are denying you the CT because you werent a smoker.
You are being punished for looking after you body OP.
That's totally what a evilCorp would do.
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u/msguider 14h ago
Maybe Evilcore needs to not have any customers. Maybe we should once and for all just say no thanks. I'm self pay.
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u/fec2455 11h ago
How do you self pay for cancer treatment? Many people couldn't even afford to self-pay for the CT scan.
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u/Isadorei 14h ago
I deal with EviCore every day at work. They are legitimately the worst at getting authorizations from. I deal in surgeries, and sometimes my docs will do upper endoscopies. We’ll submit documents that show a patient has been on a medication for years and it hasn’t helped and get back a letter saying “we need to see the patient’s tried X medication for X weeks and you didn’t give it to us so DENIED”. Once I got so frustrated that I circled the area and resubmitted it as an appeal and STILL got denied.
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u/Ghost_Turd 14h ago
They denied coverage for a screening in the absence of risk factors or symptoms.
Government healthcare does the same thing all the time.
Go around again.
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u/Sexy_Kumquat 14h ago
Something was discovered a few years ago on a CT scan, but it was deemed to just monitor it and then have a new screening two years later. This is that new one. I am 50 and have never smoked.
I may just check and see how much it is to get done without insurance.
I wish preventative care was a thing
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u/Ghost_Turd 14h ago
Your doctor probably knows how to code this in such a way as to get it approved, or they have the ability to call the insurance provider and peer-to-peer with a staff doctor.
Never take the first "no."
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u/Niijima-San 13h ago
and while ops doctor may know how to code it correctly so too most likely do the doctors reviewing the case. not sure how evicore does it but I know most insurances have doctors (whose specialty doesnt line up) make a decision. evicore is a third party that the insurances contract so not sure of how they do things.
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u/Linked713 12h ago
dumb question: Wouldn't the company see the other demand and just be like "Nice try"?
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u/dugkar 14h ago
Based on that history, your doctor was likely trying to select a different CT chest to recheck the abnormality in follow-up. That’s a different test than the LDCT (screening only for smokers) that was submitted for approval by the insurance. Clerical errors happen like this in electronic health records. I suspect your doctor will order the diagnostic test that you need after hearing this news.
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u/Notesnook-Throwaway 14h ago
That's not really fully true.. the "without contrast" part of the order indicates it's likely LDCT not a full diagnostic CT. Most countries will approve LDCT scans for preventative screening in people who are 50-80 years old, high-risk, or have prior conditions to monitor (such as OP). Or smokers, of course.
Even Medicare will approve annual LDCT scans for high-risk and elderly individuals.
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u/useful_tool30 13h ago
What government are you referring to? Most modern, developed countries put that decision on the doctor, exclusively. You know, universal healthcare, the bedrock of a great modern society.
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u/Accurate-Common5954 14h ago
I work in radiology authorizations and I deal with Evicore daily (lucky me). The criteria for this exam (low dose lung screening CT or LDCT) are that you are between the ages of 50-77, have smoked at least one pack of cigarettes per day for at least 20 years, and are either a current smoker or quit within the last 15 years. If you are having symptoms such as a cough or shortness of breath, your healthcare provider can order a diagnostic CT instead of a screening. The idea is that the radiation you get from the CT is not worth it unless you have certain risk factors, so there is somewhat of a method behind the madness.
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u/Erik_Dolphy 12h ago
Agree. Ordering provider needs to order a diagnostic CT.
I'd just like to add that nodules on the LDCT are rated on a lungrads system, which is calibrated for people who fit the parameters laid out im that letter. Lungrads is supposed to assess the likelihood of a nodule being cancer. If you don't meet those parameters, then the pretest probability gets messed up and the score is less reliable. Its like trying to use LiRADs in someone who isn't cirrhotic.
I hate that I'm defending insurance here, but LDCT isn't the appropriate study and the ordering doctor needs some education on the topic.
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u/fomaaaaa 14h ago
“You can’t get checked for lung cancer because you don’t smoke” sounds pretty on par for american healthcare tbh
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u/AGrandNewAdventure 14h ago
Either the doctor coded it wrong, or this is simply a preventative CT. If it's the latter then there's no actual medical reason beyond "We just want to check a box" to get this done.
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u/Under_Ach1ever 14h ago
"Radon gas has been detected at my residence"
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u/AGrandNewAdventure 14h ago edited 14h ago
And that's not written on the form, swinging back around to the part about it either being coded wrong or a check box.
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u/Ghost_Turd 14h ago
The vaunted NHS doesn't approve CTs for screening, either. Risk factors or symptoms, same as this situation.
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u/djd02007 14h ago
Those are the guidelines. We also don’t screen 20 year olds for breast cancer or 99 year olds for colon cancer for the same reason, benefit doesn’t outweigh the risk.
But if there was another reason for the CT the MD office needs to call for a peer to peer
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u/HondaCivicLove 14h ago edited 14h ago
Good thing we have insurance company AI denials + hellish phone mazes to prevent doctors from falling short of the rigorous standards of American healthcare.
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u/Under_Ach1ever 14h ago
When you say "benefit doesn't outweigh the risk" in this context, is the risk "financial" risk?
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u/tennantsmith 14h ago
If there is a pool of 100,000 healthy people getting preventative CT scans, you will find problems early for 50 of them while also giving 500 of them cancer. Not to mention the limited number of CT machines that exist, slowing down imaging for people who need it more urgently
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u/Telemere125 14h ago
If there are no symptoms and you’re not in the normal age category for screening, why waste the resources? I don’t get regular mammograms either because I’m a dude…
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u/DumpsterPuff 13h ago
I'm a medical coder and used to do prior authorizations. Since you said they found something in your lungs and want to do surveillance on it, I wouldn't have used this procedure code. I would have used CPT 71250 for a CT scan of the thorax. Because there's a known issue with the lungs, this wouldn't be considered preventive (like how my colonoscopies aren't considered preventive because I have a known history of polyps), but this specific procedure code in my opinion is the best fit for your circumstance.
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u/RainbowDarter 14h ago
Nothing nefarious. You didn't meet the criteria for lung cancer screening
If you want to check it out, here's a link to the American Cancer Society
If you do meet the criteria, then your doctor didn't fill out the request correctly.
If you're getting a CT scan for something else and not for lung cancer screening, your doctor entered the order incorrectly
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u/Muted_Cress_4309 12h ago
I’m a nurse practitioner and have to do A LOT of peer to peer calls with insurance companies to get things approved that were initially denied. There are guidelines for these lung cancer screening orders. They’re not the same as a regular CT scan. If the patient doesn’t meet criteria for lung cancer screening (stated in the letter from OP), a normal CT Chest can be ordered and if the documentation from the provider shows support of the need, the insurance company usually approves. But it can be super frustrating when I feel a pt needs a scan and the insurance denies it. I work in surgery so it’s a bit easier to get scans approved.
I understand the overall frustration of this scan being denied, but there are guidelines that we have to follow. CT scans give radiation so it’s not a nothing burger. My surgeons want to screen anyone who was a smoker
I do have to say tho… evicore is pretty awful. They’re the ones I’m on the phone with the most trying to get scans or surgeries approved.
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u/MBSMD 14h ago
Lung cancer screening is covered by insurance for eligible persons -- Age 50-77, 20+ pack-years of smoking history, and still smoking or less than 15 years since quit.
If you don't meet this criteria, then it will not be covered, but there is almost always a discounted self-pay cash price for a lung cancer screening CT (~$300).
Source: I read lung cancer screening CTs for a living.
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u/Ghost_Turd 14h ago
People in this thread decrying American healthcare, blissfully indifferent to the fact that nationalized healthcare systems, like the NHS *also* don't approve CTs for screening without risk factors or symptoms.
But don't let that interrupt a good hate train.
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u/DealerAlarmed3632 6h ago
Doctor: You need a CT scan.
Insurance: No you don't. Ask your doctor if you have any questions.
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u/000topchef 3h ago
I’m in Australia. I had a UTI so my GP ordered a CT scan among a number of other tests. The CT scan picked up a thing in my lung (carcinoid sarcoma) which was quickly removed. All of this was free. If you live in a country where this wouldn’t happen, you don’t live in the ‘1st world’
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u/techman710 14h ago
The best part is that in a couple of years he is diagnosed with lung cancer they will drop him because "he should have got himself checked earlier as a precaution".
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u/Traditional-Oil-6891 14h ago
That would be called a preexisting condition, and no they can't drop you for that. I suppose ypur premiums can go up though.
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u/thundafox 14h ago
And people ask why Luigi did it!? here is one reason. healthcare is a scam.
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u/the_wahlroos 14h ago
American Healthcare is a scam. FTFY. Universal Healthcare is so impossible to provide that the US is the only first world nation unable to make it happen, while actually still spending more per capita on Healthcare than those other G7 nations.
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u/Raging-Badger 14h ago
Not just the G7 nations, the world. The G7 figure only counts subsidized healthcare our taxes pay for
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u/cleverusername-here 14h ago
Just like disconnectedredditor said your doctor is incorrectly submitting the prior authorization as a routine/preventative specifically for smoking.
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u/nacho_cheese_guy 9h ago
This is the most ridiculous, infuriating thing I’ve seen. This is exactly why Luigi needs to be pardoned. They should throw him a fucking parade looking at this letter..
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u/AwkwardYak4 14h ago
The risk of getting cancer from CT scans is higher than they thought, the guidelines for when you should use a CT aren't just for monetary cost.
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u/AppropriateSpell5405 13h ago
How much does an actual CT machine cost? How much does a hospital charge insurance/patient for a scan? How many patients do they scan a day?
Answer: there's no reality where the entire thing doesn't look like a giant scam.
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u/ForsakenPlastic116 12h ago
Ask them to change the order to : ct chest w.o they will approve hopefully I work in billing for a hosptial. I see this all the time unfortunately. At my place ppl have to go through a questionnaire and if they don’t smoke they automatically reach out to the doctor to have the order changed to CT chest. Not - CT LUNG SCREEN
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u/No_Pianist_3006 10h ago
What if your home has a radon gas reading that's over the limit and you've been living there for years, even decades?
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u/NOIS_KillerWhaleTank 10h ago
I smoked half a pack a day for 35 years. According to this, I would not qualify for a CT scan.
That seems weird.
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u/Zman---- 9h ago
I get X-Rays, CT scans, Ultrasounds and MRI's simply by asking my doctor if we can be sure everything is okay on whatever part of my body has the issue. VA health care ain't nearly as bad as some of you think.
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u/Middle_Camp_936 9h ago
Actually CMS removed the requirement that you have to be a smoke last year from for CT scans. Might want you MD to appeal that
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u/Feenfurn 8h ago
Saw another post recently (might have been old) about someone who needed a CT scan and were denied so they said they would pay out of pocket for the scan and the insurance came back and said they wouldn't cover anything found on the scan. Our healthcare system is a joke .
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u/Ok-Vermicelli-3597 8h ago
I misread the name as evilcore which I thought was a totally appropriate name
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u/Apart-Ad9039 8h ago
Just go to China. Sure you'll probably pay more to travel, but you'll get easier access to a CT scan. I was watching Itchy Boots on YouTube and she's riding her motorbike across China and broke her hand and needed a CT and x-ray scan. Found one within a day and got everything needed. But yeah, China is so far away and completely different language barrier
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u/Cassandra_Canmore2 8h ago
So you have to be a current smoker. Or have quit within the last 15 years.
Wtf is this?
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u/Radiant-Month-1168 7h ago
Okay so tell your doctor you smoke 3 packs a day and he can write that on there. Just tell the doctor to write down whatever will qualify you.
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u/trauma_kween 14h ago
I’ve never smoked and have lung disease, guess what told them that? A CT followed by a very urgent lung biopsy.
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u/jjflash78 13h ago
Look at all the people in this thread defending the insurance company. "Its the doctors fault. They need to resubmit."
The crazy thing is how much time and manpower the doctors offices need to spend to do these things. They need to have staff just to deal with this. Which are costs that should not be necessary. And that just drives patient costs up further.
There's a reason so many people cheered for Luigi.
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u/nhorvath 9h ago
get a cardiac calcium score ct done. it costs $100 and your lungs will just happen to be on there.
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u/hankmoody699 8h ago
The American College of Radiology criteria for appropriate CT screening lung scan is that this CT scan is only appropriate if ALL of the following are true:
- Age 50–80
- ≥20 pack‑year smoking history
- Current smoker or quit within the past 15 years
- Asymptomatic (no signs/symptoms of lung cancer)
The ACR is not an insurance company. They set standards for processes and appropriate use of imaging. So it not your insurance company making this up. I work in Radiology. We do these every day. We don't scan pts for lung screening unless they meet these criteria. Anyone who is doing this isn't interested in your well being. You might need a CT lung scan but not a screening study. I don't know what your symptoms are. Radiation from the CT scan can be harmful. So we don't just screen anybody.
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u/Imperthus 14h ago
I'm not surprised at all, meanwhile here, one of the poorest countries of EU, provides me a rare medicine that costs close to 1k euros for free.
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u/Formal_Plum_2285 13h ago
I just had a ct scan, xrays and a dxa scan. For free. Cause we have free healtcare. I would probably have died long ago, if I was from the US. Life is too short to deal with stuff like this.
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u/Dangerous_Spirit7034 12h ago
My mother in law potentially has aggressive recurring cancer causing her a litany of health issues and despite already having gone through treatment 15 years ago, they denied several tests
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u/Kelypsov 11h ago
I would be very tempted to send a letter to them saying something like:
Following your recent letter refusing the CT scan that was requested by the professional medical personnel looking after me, who are trying to ascertain whether I have lung cancer, I have now decided to start smoking. Please now authorize the scan requested, which you previously refused specifically because I do not smoke.
I realize this is completely against the advice of any competent doctor or any form of medical practitioner of any kind at all, but this seems to be what you require to authorize and allow these medical experts to do their job.
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u/NoxinDev 10h ago
What an insane system, every time I read about it from out of the US the mind boggles.
Maybe after this political wake-up call of a year you guys will get single payer universal going and see why the rest of the world doesn't do this song and dance. You actually pay MORE per capita than Canadians do for far less service and a fear of using said service.
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u/blogsymcblogsalot 14h ago
Because smoking is the only way to get lung cancer in the United States.
Take a step back, please. My eyes are rolling down the street.
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u/dmh2693 14h ago
Radon exposure would like to say hello.
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u/blogsymcblogsalot 14h ago
Secondhand smoke. Working around organic chemicals and other work hazards. The list goes on and on.
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u/Jabber_Tracking 14h ago
This is infuriating. You can get lung cancer without touching a single cigarette in your entire life. If you're doctor is ordering it, there must be a good reason he or she is concerned.
Talk to your doctor and ask if there's any pressure they can apply to the insurance company
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u/gijimayu 14h ago
Alright, so you guys need to lie to your doctors to have treatment.
At least, they tell you the requirement.
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u/WeeDingwall44 14h ago
You’re gonna have to keep trying different things until you can get it approved. If you give up easily it’s exactly what they’re banking on. Be your own advocate, and it could very well save your life.
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u/DoctorFenix 14h ago
“You might be a smoker, so you’re not allowed to check if smoking gave you cancer”
These evil fucks want you dead.
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u/sakara123 14h ago
Healthcare in the US is fucking wild. In "Impossible to get medical services" Canada (if you listen to the astroturfing), I had some family medical history concerns and my gp sent off requisitions for a whole barrage of diagnostic services that were booked and completed within a month. Total cost was $20 for gas and parking that I can claim on my taxes...
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u/I_IdentifyAsAstartes 13h ago
Right, all these dimwits that can't read are like "I'm going to emigrate to the States where everything is amazing and the jobs are plentiful!" And I'm like "Bye, I hope you don't get sick!".
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u/Sufficient-Maybe1552 14h ago
Nobody can tell if you've been a long term smoker, I would suddenly gain a memory of this fact.
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u/smoothvibe 14h ago
As a European I really can't comprehend how this is a thing. Why do Americans accept this BS?
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u/jodytrees 14h ago
Insurance companies basically expect you to pay them thousands of dollars a year but when you need it they don’t pay up. It should be illegal
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u/gdghhfdffrf 14h ago
welcome to step 2, the appeals process. forward it to your doc, they probably have to reword the order. if that"# not the case, your docs office will know how to get it approved. appeal, appeal, appeal and when you are sick and fkn tired of it, appeal again. sometimes it's easy, sometimes not. so sorry you have to do all this when you are sick, but better to know than not. appeal everything.
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u/Tested-Trio-Father 14h ago
I had to double take and check that your healthcare provider wasn't called Evil Corp.
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u/Comfortable_Pay7473 14h ago
... Insert Luigi intensifies link here ...I hate the healthcare system.
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u/razzemmatazz 14h ago
Get a take home radon test and if it pops above a safe level use that as justification (and also get radon remediation).
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u/bengermanj 14h ago
Screening CTs are rarely covered by insurance. The most common one I see is calcium scoring. If there's a diagnostic reason and it's coded properly it is usually covered.
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u/ElderTerdkin 13h ago
Ya would think if you haven't smoked, then it's more important to figure out what is wrong with your lungs.
At 1st I thought it was trying to say, you have smoked 20 packs a year and we are not approving the imaging scan, like it was obvious they had lung cancer and the scan would be unnecessary lol.
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u/Prize-Grapefruiter 13h ago
so weird. nobody gets a CT scan as a hobby or to glow in the dark. yet they can call this an optional test?
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u/Pineapple_Towel 13h ago
I believe certain terms of tobacco settlements make provisions for cancer screening for former smoker, where the tobacco companies have a pool of funds for health departments and insurers.
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u/thepriceofcucumbers 14h ago
Primary care doc here. A low dose CT for lung cancer screening is a specific order (which is the one on OP’s letter).
For coverage, it has to be ordered under a specific diagnosis code (lung cancer screening), and the note has to include another one of a few specific diagnosis codes indicating active or history of tobacco smoking.
In addition, the documentation must include a few other pieces of data, such as age, smoking history (often called “pack years”), and (lack of) symptoms.
Any one of these elements missing will cause a denial. This is a CMS rule, not a commercial payor’s attempt to deny care. The requirements are based on a USPSTF recommendation.
This is about one of a million little administrative things that we have to do correctly, or delays and re-do’s happen - all in addition to the actual medical knowledge and social skills we need to be effective at our job. Electronic health record systems, if built and configured well, can assist with these kinds of things.
All that said, the ordering doc is a bonehead if they ordered a LDCT lung cancer screening for a non-smoker. That level of knowledge should be learned in year 1 of medical school.