PET Scans and Genetic Testing: What Insurance Covers

PET scans and genetic tests are two of the most common things people with cancer, or a family history of it, find their insurer will not pay for, at least not the first time. Both are usually covered when they will change a treatment decision, and often refused when the plan thinks another test answers the same question. This guide explains how the rules work, how to get a PET scan approved, what genetic testing coverage looks like, how a test result can and cannot affect your insurance, and where a written second opinion can help.

Does insurance cover PET scans for cancer patients?

Usually yes, when the scan is needed to stage the cancer or plan treatment and the insurer agrees it is medically necessary, but most plans require prior authorisation first. Denials are most common early on, when the plan thinks a CT scan or bone scan is enough.

Medicare sets out its rules for FDG PET in a national coverage decision. It covers one FDG PET scan to plan the first treatment when a cancer is biopsy proven or strongly suspected and the treating doctor decides the scan is needed. After the first course of treatment, three FDG PET scans are covered nationally to guide further treatment, and coverage for more than three is decided by the regional Medicare contractor. Some uses are not covered at all, for example FDG PET to plan the initial treatment of prostate cancer (CMS, NCD 220.6.17). Private plans write their own rules, which often follow a similar logic.

How do you get a PET scan approved, and what if it is denied?

The request needs to show how the result would change the plan. Your doctor sends the prior authorisation with the pathology, staging and imaging reports and the specific question the scan should answer. If it is denied, ask for a peer-to-peer call between your doctor and the insurer's reviewer, and for an urgent appeal if waiting could affect your treatment. Our guide to cancer insurance appeals covers the deadlines.

It is also fair to ask your oncologist whether the PET would change anything. Sometimes the answer is that the approved tests are enough. If you want the scan anyway, you can pay for it yourself; prices vary widely.

Our cancer service works from the reports you already have and does not book scans. A scan done abroad would also need your own doctors to accept it, so talk to them before you consider one.

Does insurance cover genetic testing for cancer?

It depends on why the test is done. There are three common situations, and plans treat them differently.

For people without cancer but with a family history, HealthCare.gov lists "breast cancer genetic test counseling (BRCA) for women at higher risk" among the preventive services that plans must cover in network without cost-sharing. Whether the test itself is covered at no cost depends on your plan and on meeting its risk criteria, so ask before the sample is taken. For people who already have cancer, testing that guides treatment is judged on medical necessity like any other test, usually with prior authorisation. Other tests, such as carrier screening before pregnancy or tests that predict how you will respond to some medicines, have their own rules, so check each one separately.

Coverage can still cost you more than paying directly, if your deductible has not been met.

If a test is refused, ask the lab for its self-pay price and whether it runs a financial assistance programme, and ask your doctor whether the plan's criteria are met and simply were not documented.

Can a genetic test for cancer risk affect your insurance?

For US health insurance, no. Under the Genetic Information Nondiscrimination Act (GINA), health insurers may not use genetic information to decide whether you can get cover or to set your premium. GINA does not cover life insurance, disability insurance or long-term care insurance, although some states have passed wider laws (National Human Genome Research Institute).

If you are thinking of buying life or disability cover, it is worth looking into the timing before you test, and checking your state's rules. Outside the US, the rules are different, so check locally.

Where can a written second opinion help?

When your doctors and your insurer disagree about which tests you need, or you want another view of your staging before a big decision, a second opinion gives you and your doctor a second team's reading of the same reports. It does not order tests and does not replace your own doctor.

We pass your reports to the multidisciplinary team of a partner hospital in China. The team reviews them with your questions and issues a written opinion signed by its licensed doctors, with an English translation and the Chinese original. It can cover the team's view of your diagnosis and staging, the treatment options they see and any further tests they think are needed, including whether a PET scan or genetic test would add information. We work from reports, not raw scan files, and do not give medical advice ourselves. Before anything is sent, we tell you the hospital, the fee and the expected time, and ask for your separate consent to send your records abroad.

Coverage rules change and differ by plan. Confirm the details with your insurer before any test.