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September is <\/em><\/em>Gynecologic Cancer Awareness Month<\/em><\/em><\/a>.<\/em><\/em><\/p>\n After Kay Hsu was diagnosed with advanced, stage 4<\/a> breast cancer in 2018, she had a PET scan<\/a> \u2014 an imaging test that can detect and analyze tumors \u2014 every four months. For six years, these scans were a routine part of her care and were covered by her health insurance.<\/p>\n But in September 2024, things changed.<\/p>\n Hsu\u2019s insurer denied her PET scan, claiming it was \u201cnot medically necessary.\u201d<\/p>\n \u201cI was so upset that I could hardly see straight,\u201d Hsu recalled. \u201cI had never been denied a PET scan. I have stage 4 breast cancer, which is incurable, and scans every four months are the standard recommendation from my specialist.\u201d<\/p>\n Hsu, an advertising creative director in New York City, said that despite paying her premium and copays \u2014 everything she is supposed to do to maintain her coverage \u2014 she was still denied essential care.<\/p>\n Hsu\u2019s doctor submitted an appeal to Hsu’s insurer, Cigna Healthcare, but they upheld the denial. Despite Hsu’s advanced cancer diagnosis, both denial letters stated that “the service requested is not medically necessary.”<\/p>\n \u201cThe realization that this private company can have so much power over whether you live or die \u2014 it\u2019s a huge burden, on top of having cancer,\u201d said Hsu, who filed a complaint against her insurer over the denial.<\/p>\n Ultimately, Hsu’s employer ended up paying for the PET scan out of pocket.<\/p>\n That scan saved her life.<\/p>\n It showed that the cancer had spread to her liver. \u201cIf I had not had the PET scan, I would not have known my cancer had spread. I could have died,\u201d Hsu said.<\/p>\n Hsu had surgery to remove the tumor in her liver and continues to be monitored closely by her doctor.<\/p>\n In 2025, Hsu\u2019s employer switched to a new insurance company.<\/p>\n Hsu\u2019s experience is not an anomaly \u2014 it\u2019s a part of a growing problem where cancer patients are being denied<\/a> medically necessary testing.<\/p>\n In 2026, there will be an estimated 2.1 million<\/a> new cancer cases. Getting the right diagnostic testing<\/a> is crucial to creating a comprehensive treatment plan specific to each patient\u2019s needs, and denying these tests causes harm to people whose health depends on early tumor detection and access to specialized care.<\/p>\n Yet, denial rates for imaging continue to rise<\/a>.<\/p>\n A study published in JAMA Network found that 22% of cancer patients<\/a> did not receive the care recommended by their healthcare team as the result of insurance denials and delays.<\/p>\n Another study, published in the Journal of Surgical Research, found that 13.1% of cancer patients<\/a> received initial denials for imaging, more than half of which were eventually overturned.<\/p>\n PET scans are among the hardest tests to get approved<\/strong><\/p>\n<\/h3>\n Research shows that PET scans are significantly more accurate (86%\u201390%<\/a>) than other types of imaging because of their ability to analyze<\/a> metabolic activity in tumors.<\/p>\n That means PET scans are a crucial diagnostic tool for assessing breast<\/a> and gynecologic cancers<\/a> \u2014 and using a PET and CT scan together<\/a> represents a \u201csignificant advancement in personalized medicine\u201d and the ability to tailor treatment to each patient’s diagnosis.<\/p>\n \u201cPET scans are absolutely the gold standard for determining what stage certain cancers are in,\u201d said Julie Gralow, M.D<\/a>., the Chief medical officer for the American Society of Clinical Oncology.<\/p>\n In spite of their importance, insurers deny<\/a> PET scans up to 60% of the time for chronic medical conditions due to their high cost, claiming the scans are \u201cnot medically necessary<\/a>\u201d or \u201cexperimental,\u201d even though PET scans have been used for decades and have transformed cancer care by improving detection, treatment planning and assessing treatment response.<\/p>\n<\/div>\n Prior authorizations create delays in patient care <\/strong><\/p>\n<\/h3>\n AHIP, the national trade association representing the health insurance industry, claims<\/a> that prior authorizations \u2014 when an insurance company reviews a request for medical services to determine if they will pay for it \u2014 are a necessary safeguard that keeps out-of-pocket costs and premiums down.<\/p>\n But medical experts report<\/a> that prior authorization requirements have created significant barriers<\/a> in getting imaging approved for cancer patients and delays care, which can lead to negative outcomes, including disease progression and even death.<\/p>\n Gralow said that obtaining prior approval for imaging used to be a way for insurers to weed out unnecessary or unproven testing, but things have changed, and now medically necessary imaging is being denied.<\/p>\n \u201cThis is no longer about ensuring that we are using evidence-based care,\u201d Gralow noted. <\/p>\n Elena Ratner, M.D.<\/a>, a gynecologic oncologist at Yale Cancer Center, agrees. <\/p>\n Ratner said that prior authorization requirements have also impacted staffing. <\/p>\n \u201cMedical facilities have had to hire staff just to deal with getting prior authorizations approved. It takes a lot of manpower to get these scans authorized. There is a real risk of harm to patients when PET scans are denied. In my 25 years of practice, we have never been in this kind of predicament in healthcare,\u201d Ratner said.<\/p>\n<\/div>\n Patients have the right to appeal imaging denials<\/strong><\/p>\n<\/h3>\n Scott Glovsky, an attorney in California who represents cancer patients who have been denied imaging by their insurers, said that while getting approval for imaging has gotten harder, it\u2019s important for patients to know what their options are if they receive a denial.<\/p>\n Glovsky believes that insurers frequently prioritize profit over patients. \u201cTo insurance companies, time is money, and if they can deny or delay treatment for terminally ill patients, then they may never have to pay for that treatment,\u201d Glovsky said. <\/p>\n Glovsky recommends patients file an expedited appeal<\/a> immediately after receiving the first denial.<\/p>\n \u201cTime is critical with cancer patients \u2014 never take the first no for an answer,\u201d Glovsky added.<\/p>\n During the appeal process, doctors can also request a peer-to-peer review<\/a>, which is a clinical discussion between a medical provider and the insurance company to establish why a service is medically necessary. <\/p>\n Under the Affordable Care Act, patients also have the right to submit a request<\/a> for an external review<\/a> (an independent third-party medical professional reviews the denial) for services that were denied due to the insurer claiming they were not medically necessary.<\/p>\n<\/div>\n Many are not aware of their appeal rights<\/strong><\/p>\n<\/h3>\n In a 2023 national survey<\/a> of adults with health insurance, almost 7 out of 10 respondents didn\u2019t know they could appeal denied claims. And, according to KFF, only 4%<\/a> of patients enrolled in a marketplace insurance plan pursued an external review in 2024 \u2014 but when they\u2019re requested, many denials are overturned<\/a>.<\/p>\n Patients can also seek assistance from Consumer Assistance Programs (CAP)<\/a> \u2014 typically nonprofit agencies or independent state ombudsman offices \u2014 that assist patients with insurance issues, including claim denials. <\/p>\n People living in states without a CAP program can contact the National Patient Advocate Foundation<\/a> for assistance.<\/p>\n If patients have concerns that insurers are not following required protocol (they didn\u2019t provide patients with a written copy of their denial, or exceeded the legally permitted time frame to review an authorization request, and so on), they can file a grievance<\/a> with their insurer and also contact their state department of insurance<\/a> to file a complaint. <\/p>\n<\/div>\n Imaging denials are more than an inconvenience<\/strong><\/p>\n<\/h3>\n As Hsu reflects on her battle to get critical imaging approved, being denied PET scans continues to haunt her. Whenever her current oncologist submits the prior authorization request, she\u2019s concerned that she could be put through this ordeal again.<\/p>\n \u201cEvery time I get a letter from the insurance company, I get so much anxiety \u2014 it\u2019s really given me this terror on top of the cancer,\u201d Hsu added.<\/p>\n Denying people access to medically necessary tests can cause them anxiety that can significantly impact their health. But more than that, making decisions based on profits over people can compromise<\/a> patients\u2019 abilities to receive an accurate diagnosis and treatment for life-threatening conditions \u2014 and that can have deadly consequences. <\/p>\n<\/div>\n<\/div>\n\n\n
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