prometheus testing - how do I get insurance to cover it?

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New Member

Date Joined Dec 2007
Total Posts : 8
   Posted 3/2/2008 7:53 PM (GMT -7)   
Does anyone have any advice on how to talk my insurance company into covering the test from Prometheus?  I can't afford the $270 every time my doctor orders the test.  I've got two bills racked up already that I haven't paid, and my doc wants me to do the test again next week.  He's writing a letter for me to send stating that this test is necessary to test my Imuran levels, but if that doesn't do it - what's my next step?  Has anyone successfully fought this with the ins. co?  They say that the test is investigational in nature, and they won't cover it.  The $270 doesn't even count towards my deductible or my annual out of pocket!   ARGH!  Any suggestions?  Thanks! 
39 years old - diagnosed with Crohn's in 2007
Currently taking Imuran 75 mg

Forum Moderator

Date Joined Nov 2003
Total Posts : 7122
   Posted 3/2/2008 10:19 PM (GMT -7)   
Why is your doctor having to do this test so often? I could see a couple times to fine tune your dosage but I don't get this often. Then again, my doctor has never ordered the Prometheus to monitor my Imuran levels. He fine tuned my dosage level by monitoring CBC and liver profiles - tests insurance does cover.
Moderator Crohn's Disease Forum
CD, Ankylosing Spondylitis, small fiber peripheral neuropathy, avascular necrosis, diffuse connective tissue disease, Sjogren's Syndrome ?

Veteran Member

Date Joined Jan 2003
Total Posts : 1152
   Posted 3/3/2008 6:34 AM (GMT -7)   
There are two different Prometheus labs tests used.... shouldn't really need either "often"...... but the best way to receive approval from insurance companies is thru your doctor.

Veteran Member

Date Joined Aug 2007
Total Posts : 884
   Posted 3/3/2008 10:06 AM (GMT -7)   
My insurance through my husband has always covered mine with no problem but, my boss's daughter just had it done and insurance is saying it is investigational and not medically necesary.  They are telling them they are responsible for the $500 test.  The doctor's office is sending more letters, etc. to the insurance company and said that you just have to keep having the doctor's office try to get it approved, that the insurance company makes it difficult to fight so that people give up and pay it themselves. 
...rejoice in our sufferings, because we know that suffering produces perseverence; perseverence, character; and character, hope.   Romans 5:3-4

Regular Member

Date Joined May 2007
Total Posts : 89
   Posted 3/3/2008 8:41 PM (GMT -7)   
BC/BS covered mine( all but  20 %) when the GIs officed faxed them a note saying it was a medical necessity.  Mine was for the Remicade antibodies.

Regular Member

Date Joined Oct 2006
Total Posts : 367
   Posted 3/4/2008 8:24 AM (GMT -7)   
I'm also curious as to why your dr. thinks you need the Prometheus multiple times.  Each dr. is different...  I agree with the others that the best way to get the ins. to pay is to let the dr. office handle it.  In teh meantime make the office staff some cookies for working so hard for you!
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