Cancer screening can find cancer earlier, when treatment may be more effective. For some screenings, health insurance plans are legally required to provide coverage based on a person's age, risk factors, doctor’s recommendation, and established screening guidelines.
But what happens when a screening that you and your health care provider believe should be covered is denied?
Nevada Cancer Coalition wants to hear your story.
We are collecting experiences from Nevadans who have had recommended cancer screenings denied by their insurance. Your story can help us better understand where coverage problems are occurring and find ways to improve access to cancer screening across Nevada.
By sharing your experience, you can help us:
- Understand how often people encounter insurance coverage problems for cancer screening
- Identify the types of screenings, insurance plans and circumstances involved
- Understand where breakdowns may be occurring between health care providers, screening facilities, and insurance carriers
- Explain the real-world impact of coverage barriers through the experiences of Nevadans
- Develop educational resources for patients, health care professionals, insurance carriers, and policymakers
- Identify potential administrative, regulatory or policy solutions
Our goal is to make sure administrative barriers do not prevent Nevadans from receiving cancer screenings that should be covered.
What does Nevada law require to be covered?
There are state and federal laws requiring certain health insurance plans to cover cancer screening at no cost to you. Coverage requirements vary depending on the type of screening, a person's age and risk factors, medical necessity, provider recommendations, screening guidelines, and the type of health insurance plan.
Breast cancer screening
Nevada law requires certain health insurance plans to cover:
- An annual screening mammogram for insured people age 40 and older
- Screening or supplemental breast imaging at an age and interval considered appropriate when medically necessary and recommended by a health care provider because of personal or family medical history or other factors that increase breast cancer risk
- Medically necessary diagnostic breast imaging recommended by a health care provider to evaluate an abnormality
Nevada law also restricts cost-sharing and certain other conditions for covered breast cancer screening and diagnostic imaging, subject to exceptions established in law.
Insurance plans NOT included in this coverage are:
- Federally regulated insurance plans, such as ERISA plans or self-insured plans, such as the Culinary Union’s plan
- Public Employees’ Benefits Program (PEBP)
- Local government public employees plans
Colorectal cancer screening
Most health insurance plans that cover treatment for colorectal cancer are required to cover colorectal cancer screening. Current screening guidelines are:
- Screening for those at average risk should begin at age 45 and continue through age 75. There are multiple screening options available, and how often screening is completed varies based on the test and its results.
- Colonoscopy every 10 years, or more frequently if recommended by a doctor. If polyps are removed during a screening colonoscopy, it should still be billed as a screening colonoscopy.
- Stool-based FIT every year; requires follow-up colonoscopy at no cost if result is positive.
- Stool-based sDNA or sRNA test every 3 years; requires follow-up colonoscopy at no cost if result is positive.
Lung cancer screening
Lung cancer screening should be covered by most insurance plans based on the following guidelines:
- Patient aged 50-80 (or up to 77 for Medicare)
- Currently smokes tobacco or has quit within the past 15 years
- Has a 20 pack-year smoking history (check your pack years here)
- The process requires a referral from your primary care provider, a shared decision-making visit (either with your referring provider or with a clinician at the screening facility), and the low-dose CT scan.
Coverage requirements can vary by insurance plan.
Some plans, including certain self-funded employer plans, may be governed by federal rather than state insurance law. Your health care provider's recommendation also does not necessarily guarantee that every screening or service is covered.
When might a denial be appropriate?
Not every insurance denial means an insurance carrier has violated Nevada law.
A screening may not be covered in some circumstances, including when:
- A person does not meet the eligibility or risk criteria applicable to the screening
- The requested service falls outside applicable screening guidelines or coverage requirements
- The health plan is not subject to the Nevada law in question
Sometimes a denial may also result from an administrative issue, such as an incorrect billing code, missing documentation, or inaccurate information about a patient's eligibility.
If you are unsure why your screening was denied, you can still share your experience with us.
Need help with a denial?
Nevada Cancer Coalition is collecting stories to understand cancer screening coverage barriers. We can also assist you in answering questions about coverage and understanding eligibility, and can help you plan next steps with your insurer, the provider, or with OCHA or DOI. NCC cannot resolve individual insurance claims, provide legal advice or appeal an insurance denial on your behalf. If you share your story using the link above, there's an option to request assistance included on the form. Otherwise, you can request assistance here.
If you need help understanding your coverage, appealing a denial or filing a complaint, these Nevada resources may be able to help:
Nevada Office for Consumer Health Assistance
The Office for Consumer Health Assistance, or OCHA, helps Nevada consumers understand their rights and responsibilities under health plans and insurance policies. It provides education and advocacy related to health coverage and can assist consumers with health care and medical billing issues. Contact OCHA.
Nevada Division of Insurance
The Nevada Division of Insurance regulates insurance companies operating under Nevada insurance law and provides resources for consumers with insurance questions or complaints. Contact Nevada DOI.
Need help getting screened?
If you need help finding cancer screening services in Nevada, Nevada Cancer Coalition's ThriveNV navigators can help. Learn more here.