September is Gynecological Cancer Awareness Month.
After Kay Hsu was diagnosed with stage 4 advanced breast cancer in 2018, she underwent PET scans – an imaging test that can detect and analyze tumors – every four months. For six years, these scans were a routine part of her care and were covered by her health insurance.
But in September 2024, things changed.
Hsu’s insurer rejected her PET scan, saying it was “not medically necessary.”
“I was so upset that I could barely see straight,” Hsu remembers. “I have never been refused a PET scan. I have stage four breast cancer, which is incurable, and scans every four months are my specialist’s standard recommendation.”
Hsu, an advertising creative director in New York City, said that despite paying her premium and copays — everything she was supposed to do to maintain her insurance coverage — she was still denied basic care.
Hsu’s doctor appealed to Hsu’s insurer, Cigna Healthcare, but they upheld the denial. Despite Hsu’s advanced cancer diagnosis, both denial letters stated that “the requested service was not medically necessary.”
“The realization that this private company can have so much power over whether you live or die — it’s a huge burden, on top of having cancer,” said Hsu, who filed a lawsuit against her insurer over the denial.
Ultimately, Hsu’s employer had to pay for the PET scan out of his own pocket.
This scan saved her life.
It turned out the cancer had spread to her liver. “If I hadn’t had a PET scan, I wouldn’t have known my cancer had spread. I could have died,” Hsu said.
Hsu underwent surgery to remove the tumor in her liver and continues to be closely monitored by her doctor.
In 2025, Hsu’s employer changed to a new insurance company.
Hsu’s experience is not an anomaly – it is part of a growing problem in which cancer patients are denied medically necessary tests.
There will be an estimated 2.1 million new cases of cancer in 2026. The correct diagnostic tests are critical to creating a comprehensive treatment plan tailored to the needs of each individual patient. Denying these tests harms people whose health depends on early tumor detection and access to specialized care.
Nevertheless, rejection rates for imaging continue to rise.
A study published in JAMA Network found that 22% of cancer patients did not receive the care recommended by their healthcare team due to insurance denials and delays.
Another study published in the Journal of Surgical Research found that 13.1% of cancer patients received initial rejections for imaging, more than half of which were ultimately overturned.
PET scans are among the most difficult tests to get approved
Research shows that PET scans are significantly more accurate (86-90%) than other types of imaging due to their ability to analyze metabolic activity in tumors.
This means that PET scans are a crucial diagnostic tool for assessing breast and gynecological cancers – and using a PET and CT scan together represents a “significant advance in personalized medicine” and the ability to tailor treatment to each patient’s diagnosis.
“PET scans are absolutely the gold standard for determining what stage certain cancers are,” said Dr. Julie Gralow, chief medical officer of the American Society of Clinical Oncology.
Despite their importance, insurers reject PET scans for chronic diseases up to 60% of the time due to their high cost, claiming the scans are “not medically necessary” or “experimental,” even though PET scans have been used for decades and have transformed cancer treatment by improving detection, treatment planning and assessment of treatment response.
Prior authorizations result in delays in patient care
AHIP, the national trade association that represents the health insurance industry, contends that preauthorizations — when an insurance company reviews an application for medical services to determine whether it will pay for them — are a necessary safeguard that keeps deductibles and premiums low.
However, medical experts report that the prior authorization requirement has created significant barriers to approval of imaging for cancer patients and delayed treatment, which can lead to negative consequences such as disease progression and even death.
Gralow said that obtaining prior authorization for imaging used to be a way for insurers to weed out unnecessary or unproven tests, but things have changed and now medically necessary imaging is being denied.
“This is no longer about making sure we are using evidence-based care,” Gralow noted.
Elena Ratner, MD, a gynecologic oncologist at Yale Cancer Center, agrees.
Ratner said the pre-approval requirement has also impacted staffing.
“Medical facilities have had to hire staff just to handle prior authorization approvals. It takes a lot of staff to authorize these scans. There is real risk to patients when PET scans are denied. In my 25 years of practice, we have never been in such a predicament in healthcare,” Ratner said.
Patients have the right to appeal a denial of imaging
Scott Glovsky, an attorney in California who represents cancer patients who have been denied imaging by their insurers, said that while it has become more difficult to get approval for imaging, it is important for patients to know what their options are if they are denied.
Glovsky believes insurers often put profit over patients. “For insurance companies, time is money, and if they can deny or delay treatment to terminally ill patients, they may never have to pay for that treatment,” Glovsky said.
Glosky recommends that patients file an expedited appeal immediately after receiving the initial denial.
“With cancer patients, time is of the essence – never take no for an answer,” Glosky added.
During the appeals process, doctors may also request a peer-to-peer review, which is a clinical conversation between a medical provider and the insurance company to determine why a service is medically necessary.
Under the Affordable Care Act, patients also have the right to request an external review (an independent third-party physician reviews the denial) for services denied based on the insurer’s claim that they were not medically necessary.
Many are unaware of their rights to complain
In a 2023 nationwide survey of adults with health insurance, nearly 7 in 10 respondents did not know they could appeal denied claims. And according to KFF, in 2024, only 4% of patients who signed up for marketplace insurance requested an external review—yet when asked, many denials were overturned.
Patients can also turn to Consumer Assistance Programs (CAP)—typically nonprofit organizations or independent government ombudsmen—that assist patients with insurance issues, including claim denials.
People living in states without a CAP program can contact the National Patient Advocate Foundation for assistance.
If patients have concerns that insurers are not following required protocol (they have not provided patients with a written copy of their denial, have exceeded the legally allowed time frame for reviewing an authorization application, etc.), they can file a complaint with their insurer and also contact the state’s Department of Insurance to file a complaint.
Image refusals are more than an inconvenience
As Hsu reflects on her fight to get critical imaging approved, she continues to pursue the denial of PET scans. Every time her current oncologist submits the preauthorization request, she fears that this ordeal might be imposed on her again.
“Every time I get a letter from the insurance company I get really scared – this on top of the cancer really scared me,” Hsu added.
Denying people access to medically necessary testing can cause anxiety that can have a significant impact on their health. But more than that, decisions based on profit rather than people can jeopardize patients’ ability to receive accurate diagnosis and treatment for life-threatening conditions – and that can have deadly consequences.