Doc: Insurance firms decide ‘experimental’ tests, meds

Keith Roach
To Your Health

Dear Dr. Roach: Due to an elevated PSA (5.3) my urologist recommended a fairly new test prior to deciding on a prostate biopsy. The test is an ExoDx Prostate (Intelliscore). It is done on a urine sample and results in a score that indicates a higher or lower probability of high-grade prostate cancer.

After taking this test I received a denial of coverage notice from my insurance carrier because the test is considered experimental or investigational and not known to be effective for my condition. They further stated that the plan covers only proven procedures that are recognized as effective for the diagnosis of a condition based on clinical evidence published in peer-reviewed medical literature. I have been unable to locate any such literature.

I’m wondering if you would offer your opinion on the efficacy of this test in terms of evaluating prostate treatment progression for those with elevated PSA levels.


Dear H.M.: I reviewed the literature on the ExoDx Prostate (Intelliscore), and my opinion is that this test is likely to improve the accuracy of prostate cancer testing and reduce the number of men who will require a biopsy.

Insurance companies decide for themselves what is experimental and what is standard of care. If Medicare decides it is acceptable, most insurance companies will start paying for it shortly thereafter.

I suspect that as further studies are done, the test is likely to be confirmed as a useful tool in determining whether an abnormal PSA result needs further evaluation, but only time and study results will tell. Until then, your warning is appreciated. I know it is being used already, since readers are writing to me about interpreting the results.

Dear Dr. Roach: When I had gestational diabetes, my internist always told me my goal A1C level was between 5 and 6 percent and that 7 percent was too high. Is there a difference between the A1C goal in a gestational diabetic versus a Type 2 diabetic?


Dear N.E.: There is a difference. The issue with Type 2 diabetes is that many people are at high risk for heart disease. So, older people with diabetes, especially those with additional risk factors for heart disease, usually are advised to have an A1C goal near 7 percent. This is due to a study that showed people at high risk for heart disease were more likely to have a heart attack or death when the A1C goal was below 6 percent compared with around 7 percent.

Pregnant women have a different goal, since high levels of insulin during pregnancy cause the developing baby to get large, sometimes so large that there is an increased risk of trauma during birth. Since an increased risk of heart attack is a very small risk in pregnant women, it’s best to have as normal a blood sugar as possible (a normal A1C level in a person without diabetes is 4 percent to 5.6 percent).

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