Insurance coverage for Color Doppler

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windquest
New Member


Date Joined Aug 2010
Total Posts : 9
   Posted 8/11/2010 11:47 PM (GMT -6)   
Hello
I am considering a Color Doppler Ultrasound with biopsy if indicated and wonder if anyone that has had one can tell me if there are any problems with insurance coverage. I have Aetna, and I am getting mixed information including not covered because its experimental! I would really appreciate the help!
Many thanks

Tony Crispino
Veteran Member


Date Joined Dec 2006
Total Posts : 8128
   Posted 8/12/2010 1:16 AM (GMT -6)   
Welcom to HealingWell. This proabably not an issue, but you really need to check with the provider to make sure they take your insurance, and also with your carrier to make sure you have the proper clearance.

I hope you add a signature and tell us about your case...

Tony
Disease:
Advanced Prostate Cancer at age 44 (I am 48 now)
pT3b,N0,Mx (original PSA was 19.8) EPE, PM, SVI. Gleason 4+3=7

Treatments:
RALP ~ 2/17/2007 at the City of Hope near Los Angeles.
Adjuvant Radiation Therapy ~ IMRT Completed 8/07
Adjuvant Hormone Therapy ~ 28 months on Casodex and Lupron.

Status:
"I beat up this disease and took its lunch money! I am in remission."
I am currently not being treated, but I do have regular oncology visits.
I am the president of an UsTOO chapter in Las Vegas

Blog : www.caringbridge.org/visit/tonycrispino

Steve n Dallas
Veteran Member


Date Joined Mar 2008
Total Posts : 4834
   Posted 8/12/2010 6:12 AM (GMT -6)   
Get your Doc's office to get the info. They have all the correct procedure codes and stuff that help the insurance company.
Age 55   - 5'11"   215lbs
Overall Heath Condition - Good
PSA - July 2007 & Jan 2008 -> 1.3
Biopsy - 03/04/08 -> Gleason 6 
06/25/08 - Da Vinci robotic laparoscopy
05/14/09  - 4th Quarter PSA -> less then .01
11/20/09 - 18 Month PSA -> less then .01
05/18/10 - 24 Month PSA -> less then .01
Surgeon - Keith A. Waguespack, M.D.


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6981
   Posted 8/12/2010 8:02 AM (GMT -6)   
Welcome.
Sorry you have had to join our little group.

My experience is to have the doctor get literally everything pre-authorized by the insurance company, and check/re-check that all of the involved doctors are "in-network" before getting any procedures to avoid issues (I've had my share even after perfect paperwork.)

John T
Veteran Member


Date Joined Nov 2008
Total Posts : 4237
   Posted 8/12/2010 10:09 AM (GMT -6)   
Shouldn't be an issue; I had Tricare, which is similar to Medicare and they paid for two. If you have an HMO that needs preauthorization it could be an issue as they will always try to steer you to an in network doctor or procedure.
JT

64 years old.

PSA rising for 10 years to 40, free psa 10-15. Had 5 urologists, 12 biopsies and MRIS all neg. Doctors DXed BPH and continue to get biopsies yearly. 13th biopsy positive in 10-08, 2 cores of 25, G6 less than 5%. Scheduled for surgery as recommended by Urological Oncologist.

2nd Opinion from Dr Sholtz, a Prostate Oncologist, said DX wrong, pathology shows indolant cancer, but psa history indicates large cancer or metastasis. Futher tests and Color Doppler confirmed large transition zone tumor that 13 biopsies and MRIS missed. G7, 4+3, approx 16mmX18mm.

Combidex MRI in Holland eliminated lymphnode mets. Casodex and Proscar reduced psa to 0.6 and prostate from 60mm to 32mm. Changed diet, no meat and dairy. All staging tests indicate that tumor is local and non agressive. (PAP, PCA3, MRIS, Color Doppler, Combidex, tumor reaction to diet and Casodex, and tumor location in transition zone). Surgery a poor option because tumor is located next to the urethea and positive margin is very likely; permanent incontenance is also high probability with surgery.

Seed implants on 5-19-09, 3 hours door to door, no pain, minor side affects are frequency and urgency; very controlable with Flowmax and lasted 4 weeks. Daily activities resumed day after implants with no restrictions. Gold markers implanted with seeds to guide IMRT.

25 treatments of IMRT 6 weeks after seed implants. No side affects at all.

PSA at end of treatment 0.02 mostly the result of Casodex. When I stop Casodex next week expect PSA to rise. Next PSA in November. Treatments and side affects have greatly exceeded my expectations. Glad to have this 11 year journey finally conclude.

JohnT


142
Forum Moderator


Date Joined Jan 2010
Total Posts : 6981
   Posted 8/12/2010 4:24 PM (GMT -6)   
I've had experience with Aetna for surgery in the recent past, and am still in the civillian worker's world of insurance, not retired, not military, so no tricare, no medicare yet.

I'm not kidding. Get your uro or the prescribing doctor to pre-authorize everything and every name, even if they tell you it is not required, and if at all possible stay in network. Once they approve it, life is easier. They may decide something really isn't covered, but at least you have a scrap of paper to work with. It was the difference between $3k total exp. for the year vs. covering only 70% of "in-network agreed price" with a $9k deductible, then I would have to pay the 30%, and the delta if the provider did not accept the write-off.

Done in network, DaVinci cost me about $4k out of my pocket. Out of network, it would have been $12k minimum, probably closer to $15k out of my pocket.

I did get everything done that I asked for, but I hadn't found this site, didn't know about color doppler, so didn't ask for one. I did have some things refused as experimental, but the practice was in-network, and therefore obliged to write it off.

I know that the philosophy is that you should get the best care possible, but at $15k, I would have had to pass on treatment and hope to live to get to medicare, go bankrupt (and lose my job in the process) or win a lottery ticket. A brutal form of 'AS'.

MrGimpy
Veteran Member


Date Joined Jul 2009
Total Posts : 504
   Posted 8/12/2010 4:29 PM (GMT -6)   
Make the phone call now to make sure it is covered, later you will be making dozens of calls if they do not cover it, so in the long run you are saving a lot of time by checking first
Stats:
Age: 52, PSA (2008)=1.9
Biopsy on 01/09/09, Gleason Score = 3+3
One (1) out of twelve (12) cores was positive, plus external nodule found
Surgery (Da Vinci, robotic prostatectomy): 4/7/09
Post Op Path 3+3
Removed Catheter: 04/19/09
100% bladder control - Pad free 7/09
PSA undetectable tests , <0.01 – 3,9 and 16 months post-op
Trimix provides 100% erectile function

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3782
   Posted 8/12/2010 5:41 PM (GMT -6)   
Just ask the provider of the service to get "pre-authorization" from your insurance. No nasty surprises later on.

Does "Windquest" = "Volunteer"??

My friend (and I mean that) you are going through an awful lot of time and trouble to avoid a simple biopsy.. Chances are, you are going to get one anyway, the only difference being you are going to spend A LOT more money for yours...This is not the cosmic cross-roads you seem to think it is...

Post Edited (Fairwind) : 8/12/2010 4:48:25 PM (GMT-6)


cooper360
Regular Member


Date Joined Jul 2010
Total Posts : 161
   Posted 8/12/2010 8:26 PM (GMT -6)   
Some of us like it in the cosmic crossroads {cool term} very fitting!!!!!! Everyone's welcome..... even the cynical!!!!! Only requirement a color doppler LOL!!!! That's as nice as I can put it.....

windquest
New Member


Date Joined Aug 2010
Total Posts : 9
   Posted 8/13/2010 1:38 AM (GMT -6)   
Hi Fairwind....you are correct about windquest=volunteer, the name was taken on this forum.

I think you are quite mistaken, I am NOT trying to avoid a biopsy, I just don;t want ANY procedure just because that's what everyone gets. I have spoken to six other Doctors, and not all agree that the biopsy should be automatic....one suggested that as a whole, we are over biopsied causing additional problems. According to John Hopkins, there are 800,000 done each year. Dr. Bahn I think is on the right page...at least for me. He may, or may not take a biopsy...all depends on what he finds but more importantly, we will have an image to compare the next image with if we are still waiting. It is easier to determine changes and avoids another "shot in the dark biopsy".

Responding to my question on this thread, I have found that I might have a problem with my insurance although I don't think so BUT I found the cash price will be actually less than my insurance co pay and deductible. I could start a whole new thread on this, but I am appalled at what a rip off the medical system is here.(I have lived out of the country almost 10 years) One Doctor I talked to said that they billed out biopsies differently for each insurance company!

Anyway, this time I will pay cash, and go to California

cooper360
Regular Member


Date Joined Jul 2010
Total Posts : 161
   Posted 8/13/2010 1:18 PM (GMT -6)   
"I think you are quite mistaken, I am NOT trying to avoid a biopsy, I just don;t want ANY procedure just because that's what everyone gets. I have spoken to six other Doctors, and not all agree that the biopsy should be automatic....one suggested that as a whole, we are over biopsied causing additional problems. According to John Hopkins, there are 800,000 done each year. Dr. Bahn I think is on the right page...at least for me. He may, or may not take a biopsy...all depends on what he finds but more importantly, we will have an image to compare the next image with if we are still waiting. It is easier to determine changes and avoids another "shot in the dark biopsy."

This sounds like pretty logical thinking to me!!! Fairwind.....why are you so dismissive of color doppler?

Fairwind
Veteran Member


Date Joined Jul 2010
Total Posts : 3782
   Posted 8/13/2010 7:36 PM (GMT -6)   
I'm not! Color Doppler Ultrasound is FINE with me...It's probably a fine tool to avoid unnecessary biopsies..But we are dealing with a potentially terminal illness here so the term "unnecessary biopsy" is perhaps being misused..

If I had a PSA number three times normal and a sudden increase in velocity and infection had been ruled out, I would be BEGGING for a biopsy, not an ultra-sound exam, color doppler or otherwise...

PCa is a lot trickier than people think. That Gleason 9 core they pulled out of me during my third biopsy came from the same area that was CLEAN 14 months earlier...

I was living down in Mexico, knowing my U-doc wanted to do a third one..I was trying to avoid it anyway possible..So I went and had a PSA test done down there, hoping the number would be stable..When it came back 7.0 in May, (it was 5.6 in March) I lost all motivation to resist that third biopsy..
Age today: 68. Married, 6', 215 pounds, active, no health issues.
PSA at age 55: 3.5, DRE negative. Advice, "Keep an eye on it".
PSA at age 58: 4.5
PSA at age 61: 5.2
PSA at age 64: 7.5, DRE "Abnormal"
PSA at age 65: 8.5, DRE " normal", biopsy, 12 core, negative...
PSA at age 66 9.0 DRE "normal", BPH, Finesteride. (Proscar)
PSA at age 67 4.5 DRE "normal" second biopsy, negative.
PSA at age 67.5 5.6, DRE "normal" U-doc worried..
PSA at age 68, 7.0, third 12 core biopsy positive for cancer in 4 cores, 3 cores Gleason 6, one core Gleason 9. Finesteride discontinued, still no urinary symptoms, never had any..From age 55 to 65 I had no health insurance.

I have a date with the robo surgeon on Sept 3 but I'm keeping my options open. I'm also looking at seeds combined with IGRT which seems to be having good results with high-risk patients..
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