And physicians say it can take weeks for insurers to approve or deny some treatments or tests. If the answer is no, a doctor who wants to appeal must begin the lengthy process again.
Physicians also say it is maddening to have to seek prior authorization over and over for procedures that are regularly approved. They believe that doctors who have a history of receiving green lights for treatments or scans should be able to bypass the time-consuming process.
Dr. Debra Patt, an oncologist and breast cancer specialist in Austin, Texas, and the medical director for public policy at the U.S. Oncology Network, has testified before Congress about the problems cancer patients face.
“There need to be responsible ways to use prior authorization,” Pratt said in an interview. “It has gotten quite out of hand. I think of it as patients on a journey and prior authorization is like hurdles along the way that they may not be able to progress past.”
Texas has been at the forefront in tackling delays and denials associated with prior authorizations. The state passed legislation in 2021 known as the Gold Card Act, which exempted physicians from going through the authorization process if private insurers have approved their procedure submissions at least 90% of the time.
Last year, Texas passed a law exempting patients with autoimmune disease from having to go through prior authorization for their procedures. Dr. Ezequiel Silva, an interventional radiologist in San Antonio and chair of the Texas Medical Association Council on Legislation, said that patients with cancer and other chronic diseases should receive exemptions from prior authorization as well.
“There are a lot of patients with chronic conditions,” Silva said. “If we could find a way to exempt them from the prior authorization process, the gains for them could be monumental.”
New screening denials from Medicare
Private insurance companies aren’t the only ones ramping up denials for cancer care and screenings. This year, women at risk of breast cancer began receiving reimbursement denials from Medicare for identical ultrasound screenings Medicare approved in 2023, patient documents show.
Ultrasound screenings identify cancers that can be missed in mammograms, radiologists say. And they are imperative for women with dense breast tissue, a condition affecting nearly half of women over the age of 40, according to the National Institutes of Health.
Dr. Madhavi Raghu, a radiation oncologist in Connecticut, provided NBC News with several redacted patient records showing Medicare declining reimbursements in 2024 for ultrasound breast screenings it reimbursed in 2023. The records represent a small sample of the denials, she said.
Raghu said this shift is particularly surprising because it is occurring during the same year that the Food and Drug Administration began requiring mammography providers to notify patients with dense breast tissue that they may need additional cancer screenings. Those additional screenings include MRIs and ultrasounds for which Medicare is denying coverage.
“It’s unfair to tell a patient you have an increased risk of developing cancer and we have another test to find it, but you’re going to have to pay for that,” Raghu said. “It upsets me to see patients who come in with Stage 3 breast cancers because they didn’t have the opportunity to get screening beforehand.”
NBC asked a spokeswoman at the Centers for Medicare and Medicaid Services about this reimbursement shift, and provided her with documents showing the 2023 acceptances and 2024 denials. She said CMS’s coverage policy has not changed.
“The ultrasound or MRI scans you are referencing are covered by Medicare when provided as a diagnostic test,” the spokeswoman said. “If the scans were provided as a screening test, then Medicare is unable to cover those by law.”
Raghu pointed out that there is only one reimbursement code for a breast ultrasound, regardless of whether it is proposed as a screening or a diagnostic test. As a result, the routine denials by Medicare this year appear to place all breast ultrasounds into the category that is not covered.
Sumrall, the North Carolina neuro-oncologist, said she too has seen Medicare deny many more breast ultrasound claims this year and has heard the same thing from other doctors.
“No one can understand how Medicare reached this decision,” Sumrall said. And because private insurers look to Medicare reimbursement for policy, “it means more private insurers will follow what Medicare is doing.”
The Department of Health and Human Services did not respond to a request for comment regarding the reimbursement shift.
A potential life sentence in every denial
Hsu’s struggle with insurers began in 2015 at an otherwise happy time in her life. She received a breast cancer diagnosis just after she got engaged to her husband. Hsu, a resident of New York City, underwent surgery and chemotherapy, but the cancer moved to her spine and sternum in 2018.
In response, she began aggressive immunotherapy treatments with quarterly PET scans to monitor her metastatic breast cancer. Hsu has continued working and gave birth to her daughter, who is now 4 years old.
Source: 'Would he have lived?' When insurance companies deny cancer care to patients
