Prometheus Test & Insurance

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CrohnnieMan
Regular Member


Date Joined Aug 2008
Total Posts : 190
   Posted 7/25/2009 4:47 PM (GMT -7)   
So I was having a mild flare up and my doctor wanted to see if I could increase my dose of Imuran. So I had a Prometheus test done and came back that with my metabolism rate I should not take anymore. Well, a few days later I get a letter from the hospital stating my insurance denied my lab test. Then I get a letter from the insurance company showing the denial for: Services are experimental/investigational and not medically necessary. It also says, Procedure/Treatment is deemed experimental/investigational by the payer.

Ok, as soon as I saw the words "Not Medically Necessary" I almost exploded in rage, but took a deep breath as I didn't want to exacerbate my symptoms. Wow, they better be glad their service line is closed on the weekends and I have time to cool down. How is checking to see if I can increase my medication for a Chronic conidtion "Not medically necessary"? And I do not believe this test is "experimental" or "investigational". Maybe the person who reviewed the claim was having a bad day, because this is not the first time I've had this test done before and had no issues in the past.

Sorry for the rant, but I have read other stories of people having issues and want you to know you are not alone... ugh.. Anyone else have this test done and denied in the past?

pattytx
Regular Member


Date Joined Jun 2006
Total Posts : 139
   Posted 7/25/2009 5:53 PM (GMT -7)   
I had the test done several years ago.  My husband handled the insurance company (I get it through him), the dr.'s office, etc. and it was a  hassle, but it eventually got covered.  I hope you can get it done, too.  Good luck!

CP64
Regular Member


Date Joined May 2007
Total Posts : 69
   Posted 7/25/2009 6:05 PM (GMT -7)   
fight with your insurance company--specify it is the only lab that does this test!! Don't take no for an answer--My insurance now pays for this bill with no questions--they know!! Good Luck!!

spookyh
Veteran Member


Date Joined Oct 2008
Total Posts : 1342
   Posted 7/25/2009 10:10 PM (GMT -7)   
Prometheus and insurance are a major pain. I've had Prometheus send a collection agency after me on two different occasions (a very rude collection agency with snotty employees). Luckily, I was able to successfully petition my insurance company and get it worked out. Plus, there was a kind employee at Prometheus that helped me too. Wish I could remember her name, I'd give it to you!
34 years old, Crohn's disease for 15 of them
Current Meds: Humira since 7/08, Pentasa, Effexor XR
Supplements: 3 kinds of Fish Oil, Multi-Vitamin, B-Complex, Vitamins D, E, & K, Calcium, Magnesium, Enzymes
SCD since 12/01/08 - eating Stage 3 foods


CrohnnieMan
Regular Member


Date Joined Aug 2008
Total Posts : 190
   Posted 7/25/2009 11:45 PM (GMT -7)   
I just don't get why they would have covered it before, but not this time. I will not go down without a fight, just bites that I will be leaving on vacation Wednesday during all of this.

Thanks spooky, if they give me any trouble, I may call Prometheus people and see if they can provide some help.

tsitodawg
Veteran Member


Date Joined Sep 2006
Total Posts : 845
   Posted 7/26/2009 1:23 AM (GMT -7)   
I would just remind your insurance company that Imuran can cause severe liver damage if not checked regularly and that if your dose is off then you will have to undergo an expensive live biopsy. This would make the promethius test very pertinant and medically necessary. If they would rather not cover the promethius test, have your doctor send them a letter reminding them of all of the necessary testing that also go along with the liver biopsy. This is what worked for me when I was on methotrexate and had another insurance company and I never had a problem after that. They even covered my serology 7 testing from promethius.

tsitodawg
Veteran Member


Date Joined Sep 2006
Total Posts : 845
   Posted 7/26/2009 1:27 AM (GMT -7)   
Quick follow up to my other post, I forgot to mention that the company did not originally cover the test and I ended up having the expensive liver biopsy and testing that goes with it. The insurance company then ended up covering not only the full cost of the liver biopsy but also the promethius testing. Most insurance companies do not understand this disease and it takes a fight to get them to pull their heads out from doing their own visual colonoscopy if you know what i mean.

indigosunrise
Regular Member


Date Joined Nov 2007
Total Posts : 497
   Posted 7/27/2009 10:27 AM (GMT -7)   
I had the Serology 7 test done and my insurance did not cover it.  I had my GI's office submit two letters to my insurance, and it was still denied.  In the meantime, Prometheus was coming after me for payment...I contacted my insurance directly and they said to submit an appeal and I did so, only to find out they have a 6 month window on appeals and I missed it by a week.  As it stands, I was left with the entire bill.
 
I was irritated I had the test done for a couple of reasons.  First, my first GI had the blood test run right after I had my scopes, so I was groggy and had no idea what they were testing me for.  Second, and I am sure the GI knows this from past experience, I wish they would have asked me BEFORE doing the test, so I could check with my insurance company.  I realize doctors want to do what's best but with something that it seems most insurances see as "experimental" they should, at least, give you a choice and the chance to see if it is covered first.
 
If I had to do it again, I would have been a lot more pushy with both the doctor's office and my insurance.  I wish you the very best of luck with getting this covered!

ZenaWP
Veteran Member


Date Joined Aug 2007
Total Posts : 884
   Posted 7/27/2009 10:45 AM (GMT -7)   

I had the test done a few times and it was always covered.  Then, I had it done again and received the same response that it was not medically necessary.  Turns out, some minor changes had occured in my health plan (and I didn't realize it) and it was no longer covered.  I fought for months on this...dr. sent letter saying why it was necessary and their "medical expert" at the insurance company didn't agree.  I tried finding out what billing codes they used this last time compared to previous claims that were paid but insurance couldn't tell me what code was used previously because that would be telling me "how to get the claim paid" and they "can't do that." 

I told my doctor and he gave me some pamphlet from Promethius telling what % insurance companies are supposed to write off.  I tried giving them this information and they said it was incorrect.  Here's how I finally got it written off: the EOB from the insurance company said the cost was the provider's responsibility and I wasn't supposed to pay it because it wasn't covered.  Norton disagreed with the EOB.  I told my doctor again and he informed me that he had stopped using this hospital's labs because they jacked all their prices up and it was ridiculous (I think they were charging about twice what they had charged the previous year).  He told me to threaten to report them for price gauging.  So, when they wouldn't listen to anything else, I told them that both my insurance company and dr. said I should either report them or sue them for price gauging and for not writing off what insurance said should be written off (this IS what insurance and my doctor told me).  It got written off after that and I didn't pay a cent. 


Crohn's Disease, Acid Reflux/Gastritis, Hashimoto's Thyroiditis, Endometriosis, Arthritis, Depression/Anxiety.  Too many meds to list them all.  =) 


CrohnnieMan
Regular Member


Date Joined Aug 2008
Total Posts : 190
   Posted 7/27/2009 9:12 PM (GMT -7)   
Called the insurance company today and was told I had to meet some conditions:
- Be on azathioprine
- Or be on 6-MP
- And have IBD
- And have a Blood count test that is high

I am glad I called when I did because she was very helpful. As soon as I hung up the phone it hit me, I take Imuran (Azathioprine), Crohn's is IBD and had a Blood Count test done recently that showed I was in a flare. I called back and the lady wasn't as helpful and I had to tell her to go pull the medical papers to read what the last lady did. She finally did and I explained to her what I have and take. She is forwarding it back to claims so it can be reviewed again with the information I gave her. Boy, you think they would know when I fill my prescriptions and they approve IBD related claims all of the time for me....

spookyh
Veteran Member


Date Joined Oct 2008
Total Posts : 1342
   Posted 7/27/2009 10:04 PM (GMT -7)   
Insurance companies can such ignoramuses sometimes. Mine wouldn't approve Humira for me because they said I hadn't tried all the lesser drugs yet, including Imuran. I told them I had tried them all, including Imuran. They had been paying to have me fill the Imuran prescription for a couple of years (you would think there would be records of such things). However, they still claimed I had never taken the med, even when my doctor verified it. I ended up getting the Humira from the Abbott Patient Assistance Program instead.
34 years old, Crohn's disease for 15 of them
Current Meds: Humira since 7/08, Pentasa, Effexor XR
Supplements: 3 kinds of Fish Oil, Multi-Vitamin, B-Complex, Vitamins D, E, & K, Calcium, Magnesium, Enzymes
SCD since 12/01/08 - eating Stage 3 foods


CrohnnieMan
Regular Member


Date Joined Aug 2008
Total Posts : 190
   Posted 8/6/2009 6:13 PM (GMT -7)   
So the insurance stood by their decision and said still not necessary, but was given a number my doctors office could call. I called the Dr. office and the nurse thought it was outrageous and is going to contact them. She called me back and said she wrote a letter stating why it was necessary and will let me know if she hears back from them.

CrohnnieMan
Regular Member


Date Joined Aug 2008
Total Posts : 190
   Posted 8/18/2009 9:32 PM (GMT -7)   
Great News! Got a voice mail from my doctors office today and said the insurance company is paying the $560 bill. I just checked online and they haven't updated it yet, but am happy to hear the good news.

pups62
New Member


Date Joined Aug 2009
Total Posts : 13
   Posted 9/4/2009 1:55 PM (GMT -7)   
I also had problems with my insurance paying Prometheus. However, after I sent the insurance a letter staating that I had no control over who they send the test to and that Prometheus is the only company commercially doing this type of testing, they too paid for it. pups62
Had Crohns' since I was in my early twentys and now am 65 years old. On Mercaptopurine 50mg and Balsalazide 750 mg. I am lucky from what I have been reading. No bowel resection yet and it has been a while since a flare.

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