I am Pure O (OCD). I need to get a pre-approval for PET scan of brain from CIGNA insurance. Can anyone help me in this regard? Every time I submit claim they reject it by saying that it is not “medically necessary”. I have been misdiagnosed in the past and have been under psychiatric treatment for almost 7 years. My consultant has advised me if we can have a PET scan. Can anyone help me in proving it that it is medically necessary for OCD since I have been misdiagnosed in the past.
I’ve worked in health insurance in America for about 25 years. With that in mind…
Odds are you won’t be approved for a PET scan. At this point in time OCD is not diagnosed via scans. Scans have been used in research but not as diagnostic tools, therefore it’s not medically necessary to your diagnosis and treatment. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5052949/
MRI or CT scan study reported significantly decreased volume of caudate nucleus in patients with OCD as compared to normal healthy controls. Theses are much cheaper tests and may have better odds of being approved, but I would say the odds are still low because, again, these tests were done via research, not for diagnostic reasons.
OCD is currently diagnosed via anecdotal information and behavior patterns and treated with medication or with behavior therapy. Scans are not considered to be the standard of care for this situation.
I am really thankful for your response. I dont know on what basis my pscyahitrist are suggesting this. Do you have any good reason for doing this only for OCD. Just one more thing for my knowledge. Since you have worked with insurance so definitely your experience is quite diversified in guiding me. Can you please explain me how to convince one specifically insurance for the term medically necessary? What are the parameters? What are convincing reasons?
I have to agree with Azurelle, you are highly unlikely to get approval for a PET scan for OCD as such scans cannot define OCD. PET can show blood flow within the brain which may have an influence, but it is not definitive.
I’m in Australia and although our health system is primarily govt funded obtaining approval for a PET is usually only given when other test prove an issue. For example I have a brain issue, initially I was sent for a CT scan, this showed there was an abnormality, from there I was sent for an MRI which gave them a clearer image, then from that I was sent for a bone scan. Had the CT shown that there was no physical issue, the other scans would not have been ordered.
Merl from the Moderator Support Team
As I mentioned PET Scan is not considered a standard treatment or Dx for OCD. Additionally, that particular scan is extremely expensive, it’s only used after other tests have shown a medical need for specific additional information. Since OCD is not going to officially show up on any machine-based test you’re not going to get approval for one. I haven’t been able to come up with a single reason a non-required/non-diagnostic test would be approved, particularly one that’s already third or fourth in line after a host of other tests have shown a need for more detailed information.
I don’t understand what your doctor is trying to achieve. PET Scans are not diagnostic tools for your situation. Actually, no machine-based test is considered as a way to Dx your condition so no insurance company is going to approve the cost.
Think of it this way – would you take your car to a wedding photographer to have them take pictures of the engine to try and figure out what’s wrong? Or would you take your car to a mechanic for a workup?
A PET scan is like a wedding photographer, a good psychiatric team is like a mechanic.