Insurance company will not cover my MRI
Wondering if anyone out there has run into this: I went in for my annual mamo and to make a long story short I ended up having a MRI as the radiologist was not comfortable with the findings in the mamo and ultra sound. I have dense breasts and I guess it's like trying to find a needle in a haystack. Years ago I also had a biopsy because of microcalcifications. However, my insurance company does not feel this MRI was "medically necessary" and therefore will not cover it. My doctor ordered this MRI so I feel it was medically necessary and should be covered - I didn't have it just for the heck of it. I can't beleive this is going on when there is so much talk about finding breast cancer in the early stages. Does anyone know where I can go to get some help with this situation?
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My insurance company did not want to pay for my MRI guided biopsy after I already had the full workup of: mammogram, ultrasound & MRI. From all of those tests I needed the MRI biopsy. My BS spoke to the manager of the MRI clinic and got them to get the MRI covered and the portion that wasn't covered by my insurance they waived. So basically I did not need to pay for it. Maybe call where you had the MRI and speak to the office manager. Tell them you simply can't afford to pay it. I also know at my hospital they have an assistance program that people can apply for. Hope this helps.
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You can also get the doctor to help you appeal the denial either by phone or letter.
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Seems like your physician's office should have gotten the approval from your insurance company before you had the MRI, so that you would know what, if any, financial responsibility would be yours. Since it sounds like they didn't do that, perhaps with your doctor's help, you could file an appeal with your insurance company now, indicating why, in his opinion, this was a necessary procedure for your well-being. Let whoever did the MRI know you're appealing it, because it may take awhile for your insurance company to review the case again.
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Your insurance should have an appeal process. Talk to the radiologist and they should resubmit the billing according to that process. Insurance companies often reject these tests hoping that you won't call their bluff and appeal. It would be better if they'd do that before you have the test...
Good luck.
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My oncologist informed me at my last appointment that many insurance companies are not paying for MRI's~ Including those of women ALREADY diagnosed with breast cancer. Apparently, they feel that the only ones that are TRULY medically necessary are those of women who have had positive results from genetic testing. UNBELIEVABLE! I'm already bracing for the fight in April when my yearly MRI is due...
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My insurance will cover my MRIs due to high risk from LCIS and family history, yet won't cover genetic testing--go figure!
Anne
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I was told the same as Jaredsmom. Looks like we have to fight to get MRIs done. IMO the insurance companies are practising medicine without a medical degree. They will continue to get away with this if we don't speak out.
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cp418 - You are so right - in reading these boards, the experience many people have is that the insurance companies say no first and hope you just go away. It seems like they will say no up to 3 times, then they give in. Please appeal this, they should not get away with denying you a test that is considered an appropriate test for some one in your situation.
Good Luck!!
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My insurance denied the first request and then okayed the 2nd one - but I had to stay on top of it - they said they had sent a letter to me and my doctor both letting us know it had been approved, but neither of us got it - I had them fax me the okay and had mine the next day - I also kept getting the run around with people at the insurance company not knowing how to find out if the approval had come through - be persistent!
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Did try for approval for MRI--One year ago, then six months ago, the insurance company covered the MRI's. This time they have refused. The surgeon appealed, insurance company refused again. I just received my official letter from the insurance company. They state the MRI is experimental or in an investigative stage. One year ago, a lump was removed, benign. I do not have cancer. My family is 5 daughters, one son. Oldest sister had nonHodgkins lymphoma almost twenty years ago, radiation treatments, etc. She now has stage four breast cancer. Treatment is hormones, then surgery. Two other sisters had endometriosis, uterus removed, hormone therapy. One of these has stage three breast cancer, chemo, radiation, surgery. The cousins on both father and mother's sides are aware. Two have had breast cancer, more have had lumps removed.....One cousin has the "Cancer" genes. The two sisters that were on hormone therapy are being tested. Aunts and uncles have died from cancer........I am ANGRY that my insurance company is deciding my medical treatments.....My surgeon suggested that I have both breasts removed. Wonder if the insurance company gets to make that decision too????? Do I follow through with an appeal?? I worry that the insurance company will try to drop my family's coverage....We are a family that doesn't smoke, drink, we exercise regularly, we do whatever we have to to stay healthy.....We do not visit doctor often because we are too healthy.....My youngest son's medical records were tossed out because he hadn't been in the office for three years when in elementary school !!!! I am trying to be responsible and take care of my health, my doctor is trying to keep an eye on my medical needs.....The insurance company is wanting to save money???? The alternative is a late stage diagnosis??? and greater expenses.....and risks...comments would be greatly appreciated.........
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CareCoreInternational unfortunately is now the company doing the pre-cerifications of MRI's for most insurance companies.
My MRI was also denied last week. I spoke with a supervisor several levels up and he gave me this criteria for their approvals of MRI's.
CareCore National Criteria for Imaging Version 3.200877058 MRI of the Breast Unilateral 77059 MRI of the Breast Bilateral 1-6I. When necessary to confirm rupture of breast implants in asymptomaticpatients whose screening ultrasound shows ruptureII. Asymptomatic member 3 years after the placement of silicon implantsand every 2 years thereafterIII. To detect implant rupture in symptomatic patients whose ultrasoundshows no ruptureIV. To detect local tumor recurrence in breast cancer patients who haveundergone mastectomy and breast reconstruction with an implantV. Patient with new diagnosis of breast cancerVI. To detect local tumor recurrence in breast cancer patients withradiographically dense breasts, or old scar tissue from previous breastsurgery that compromises the ability of combined mammography andultrasound ( A copy of the most recent mammography and ultrasoundreports must be submitted and the request referred for physicianreview)VII. To detect the extent of residual cancer in the recently postoperativebreast with positive pathological margins after incomplete lumpectomywhen the patient still desires breast conservation and local re-excisionis plannedVIII. To detect and stage patients with Invasive Lobular Carcinoma (ILC)for tailored therapy, especially when breast conservation is beingconsideredIX. To localize the site of primary occult breast cancer in patients withadenocarcinoma suggestive of breast cancer discovered as axillary nodemetastasis or distant metastasis without focal findings on physicalexamination or on mammography/ultrasonographyX. To evaluate patients with high genetic risk of breast cancerA. Patient is a confirmed carrier of BRCA1 * or BRCA2 gene mutations
B. Patient has a relative who is a confirmed carrier of the BRCA1 or BRCA2 gene mutation
C. Male relative with breast cancer
D. Gail model lifetime risk of 20% or more
E. One or more relatives with either 2 breast cancers or both breast and ovarian cancer
F. Family history of breast or ovarian cancer and Ashkenazi Jewish background
G. Personal or first degree relative with history of Li-Fraumeni syndrome
H. Personal or first degree relative with history of Cowden's syndrome
I. Personal or first degree relative with history of Bannayan-Riley- Ruvalcaba syndrome
XI. To evaluate patients with a high risk of breast cancer based on adiagnosis of Lobular Carcinoma In situ (LCIS) 9,10XII. History of radiation therapy to the chest between the ages of 10-30XIII. Indeterminate breast imagingA. Patients with indeterminate mammograms and sonograms if there is new onset of
1. Nipple retraction
2. Unilateral drainage from the nipple that is bloody or clear
B. All other requests for breast MRI based on indeterminate mammography and/or ultrasound
that do not meet the above criteria must be sent for physician review. All imaging reports
should be requested abnd available for the medical director to review. Only a physician may
approve a breast MRI on the basdis of abnormal mammography and or ultrasound.
XIV. Breast MRI for ANY of the following indications is not covered becausethere is insufficient scientific evidence to support its use:A. To confirm implant rupture in symptomatic patients whose ultrasonography shows rupture
especially with implants >10 years old (ultrasound sufficient to proceed with removal)
B. To screen for breast cancer
C. To evaluate breasts before biopsy in an effort to reduce the number of surgical biopsies for
benign lesions
D. To differentiate benign from malignant breast disease, especially clustered microcalcifications
E. To differentiate cysts from solid lesions (ultrasound indicated)
References:1. Berb, WA, Caskey CI, Hamper UM, et al, Single-and double-lumen silicone breast implant integrity: Prospective evaluation of MR and US
criteria, Radiology, 1995; 197:45-52.
2. Harris DM, Ganott MA, Shestak KC, et al, Silicone implant rupture: detection with US, Radiology, 1993; 187:761-768.
3. Important Information for women about breast reconstruction with INAMED silicone-filled breast implants, accessed at
http://www.fda.gov/cdrh/pdf2/P020056e.pdf November 5, 2007.
4. Rankin SC, MRI of the breast, BJR, 2000; 73:806-818.
5 Lehman CD, Gatsonis C, Kuhl CK, et al, MRI evaluation of the contralateral breast in women with recently diagnosed breast cancer, New
Eng J Med 2007; 356(13):1295-1303.
6. Saslow D, Boetes C, Burke W, et al, American cancer society guidelines for breast screening with MRI as an adjunct to mammography,
CA, A Ca J Clin, 2007; 57(2):75-89.
So, this fellow told me most MRI's are denied because the doctors do not word the request within these guidelines.
I am appealing.
But he actually told me it might be faster to have another member of my medical team make the request for a pre-certification of the MRI and make sure the wording fits into one of the categories that they will approve.
I cannot even believe this baloney. And all this for my $1,500 a month premium!!
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My doctors first request for an MRI was denied. Then my breast surgeon requested and it was denied as well. I don't know what he did but his assistant told me he got on the phone with the insurance company......my MRI was scheduled within the week. I'm sure it was also a mission of "wording"
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Thank you all, I am so relieved to find this web site.......
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mine was denied recently.. a call from the doctor undenied it.
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The following guidelines by the AMERICAN CANCER SOCIETY is why I have been refused a MRI for two years in a row. I had to appeal BLUECROSS AND BLUESHIELD twice to get an MRI. I had to appear before a panel of six people and give all of my evidence to them. It was very very very hard to have to go over my entire history. Breast cancer, 1991 and 2003. Lumpectomy, chemo, radiation. They told me that BCBS insurance used the AMERICAN CANCER SOCIETY GUIDELINE to determine IF I AM ELIGIBLE FOR AN MRI. So now the ACS is telling me if I CAN HAVE AN MRI. Neither of the breast cancers were found on mammo's. One not on ultrasound. The American Cancer Society considers NOT a high risk candidate for MRI.
So therefore I NO LONGER give any credibility to the American Cancer Society. Please see below. MG
AMERICAN CANCER SOCIETY:Breast cancer
MRI scans are more sensitive than mammograms, but they are also more likely to show spots in the breast that may or may not be cancer. Often there is no way of knowing whether or not these spots are cancerous short of a follow-up biopsy or some other invasive procedure. That is why the test is not recommended for women with an average risk of breast cancer, the guideline says.
"As with other cancer screening tests, MRI is not perfect and in fact leads to many more false-positive results than mammography," explains Christy Russell, MD, chair of the ACS Breast Cancer Advisory Group and co-author of the new guideline. "Those false-positives, which can lead to a high number of avoidable biopsies, can create fear, anxiety, and adverse health effects, making it imperative to carefully select those women who should be screened using this technology."
For women at average risk, ACS recommends getting annual mammograms and breast exams by a physician, beginning at age 40. Most high-risk women should begin getting MRIs and mammograms at age 30, the new guideline says, unless they and their doctor think it's better to begin at a different age.
Better Evidence for Many Situations
The new guideline is published in the latest issue of the ACS journal CA: A Cancer Journal for Clinicians. It recommends MRI screening in addition to mammograms for women who meet at least one of the following conditions:
- they have a BRCA1 or BRCA2 mutation
- they have a first-degree relative (parent, sibling, child) with a BRCA1 or BRCA2 mutation, even if they have yet to be tested themselves
- their lifetime risk of breast cancer has been scored at 20%-25% or greater, based on one of several accepted risk assessment tools that look at family history and other factors
- they had radiation to the chest between the ages of 10 and 30
- they have Li-Fraumeni syndrome, Cowden syndrome, or Bannayan-Riley-Ruvalcaba syndrome, or may have one of these syndromes based on a history in a first-degree relative
The recommendations are based on studies that were published after the ACS last revised its breast cancer early detection guidelines in 2002-2003. At that time, the panel concluded there was not enough evidence to recommend for or against MRI in high-risk women, so the guideline advised these women to make the decision after talking with their doctor. Now there is more solid evidence that MRI is useful for certain women.
"These guidelines are a critical step to help define who should be screened using MRI in addition to mammography, a question of significant importance as we discover women at very high risk of breast cancer can be diagnosed much earlier when combining the two technologies rather than using mammography alone," says Russell, co-director of the University of Southern California/Norris Cancer Hospital Lee Breast Center.
More to Be Learned for Other High-Risk Situations
For some women, however, the jury is still out on whether MRI screening is beneficial, even though they have conditions that do give them a higher-than-average risk of breast cancer. The guideline says there still isn't enough evidence to recommend for or against MRI screening in women who:
- have a 15%-20% lifetime risk of breast cancer, based on one of several accepted risk assessment tools that look at family history and other factors
- have lobular carcinoma in situ (LCIS) or atypical lobular hyperplasia (ALH)
- have atypical ductal hyperplasia (ADH)
- have very dense breasts or unevenly dense breasts (when viewed on a mammogram)
- have already had breast cancer, including ductal carcinoma in situ (DCIS)
Screening MRIs are not recommended for women with a lifetime risk of breast cancer below 15%.
MRI Also Useful in Contralateral Diagnosis
Although the ACS guidelines find screening MRIs of uncertain value for breast cancer survivors, a newly published study shows the scans can be useful for finding tumors in the opposite (contralateral) breast of women newly diagnosed with the disease.
As many as 10% of women with breast cancer develop a new tumor in the opposite breast, even though nothing is found when they are checked with mammograms and physical exams at the time of their original diagnosis. Finding these cancers earlier could help women make treatment decisions (some women with cancer in just one breast opt to have both breasts removed as a precaution), and might spare them from extra rounds of surgery and chemotherapy later.
- Citations: "American Cancer Society Guidelines for Breast Screening with MRI as an Adjunct to Mammography" Published in the March/April 2007 CA: A Cancer Journal for Clinicians (Vol. 57, No. 2: 75-89). First author: Debbie Saslow, PhD, American Cancer Society.
MRI Evaluation of the Contralateral Breast in Women with Recently Diagnosed Breast Cancer Published in the March 29, 2007 New England Journal of Medicine (Vol. 356, No. 13: 1295-1303). First author: Constance D. Lehman, MD, PhD, University of Washington Medical Center, Seattle.
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Ditto. I have been denied twice by Blue Cross Blue Shield based on the ACS Guidelines as well. It drives me crazy and makes me so angry. I have very dense breasts, a known risk factor. At original diagnosis, my IDC did not show up on my mammogram and only a "slightly suspicious" area showed on the ultrasound. The radiologist was so unconcerned that he was waffling on performing a core needle biopsy. I said "if there's any doubt, let's just do it and be sure". I am still unable to get MRI's covered by BCBS. A few months ago, I just went ahead and had the MRI for peace of mind. I'm now appealing their decision not to pay.
How do we change this?
Lila
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Wow, I had no idea that a Stage II individual would be turned down for MRI's!!! That's incredible!!! Lila, and others, I would take copies of what Emanrasue has above, write a well thought out letter, stick to the facts and then cc to your local representative, congressman (in US).. I was having all sorts of trouble with insurance but when I did that all of a sudden they were paying on things that *I* thought I should be paying for. I hate to take such a strong stand but when a doc issues a script for MRI (or anything for that matter) and an insurance company turns it down - they are now interferring with the doctor/patient relationship and going to your rep really, really helps.. Again, as I have said before pick your battles, write a clear and concise letter (stick to the facts - they honestely don't care of feelings) and cc (Make sure that cc is not "blind" put it right on the letter to the insurance company) to a local representative if in the US a congressman/women. And good luck - we shouldn't have to do this when we are dealing with so many other things but that's what they (insurance companies) count on that we will not persue beyond a "no" response.. Good luck to all - and here's to better health care!
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My situation is similar to the others here. I did have an MRI last January, after a US-guided biopsy found IDC in my left breast. The tumor was palpable but was never seen on a mammogram, due to my dense breast tissue.
My surgeon ordered the MRI to see if there were any other tumors in that breast or on the other side. The MRI had to be pre-approved by my insurance company, and they waffled for a day and a half but finally OK'd it. The key factors were that I had already been dx'd with BC, so this MRI wasn't being used for "screening"; and mammography had failed to detect the tumor we knew I had.
Six months after my surgery (mast/SNB with no recon), I had a follow-up mammogram on my remaining breast. The radiologist said the tissue was too dense to see anything, and I would need some other imaging to evaluate any abnormalities that were found by me or my docs.
I asked my surgeon if I could have an MRI to screen my remaining breast, and she said no. She said there was not enough evidence of benefit for using MRI as a screening tool in healthy breasts. Then she said she didn't want me to end up paying for it, because my insurance wouldn't cover it anyway. She said my insurance would pay for MRI if it was done to further evaluate a breast that had already been dx'd with a malignancy--but not for screening.
That's where we are. And, yes, this is all based on ACS or other "official" guidelines. Those guidelines are all based on published clinical data. So, the problem is that there isn't enough data from controlled clinical trials showing a "benefit" from MRI when it's used as a screening tool, except in women at "very high" risk of BC. That would be women who have a BRCA mutation, women with a biopsy showing LCIS, women who had radiation therapy to the chest at a young age, etc. (as quoted in the previous posts).
The one thing the ACS guidelines do mention is using MRI for screening women with a lifetime risk of BC that is 20 to 25% or greater, according to the accepted risk assessment models (e.g., the "Gail" model). The trouble is that those models don't factor in whether a woman has already had BC. Also, the most widely used models don't consider dense breast tissue as a risk factor (yet). One reason for that is because radiologists don't all agree on the importance of breast density as a risk factor. Also, even those who do think dense breast tissue is a risk factor will admit that there is no standardized, objective way to measure and report breast density.
So our insurance companies, always on the prowl for ways to save money, are using the lack of published evidence as grounds for denying "screening" MRI's.
otter
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Emanresu: I'm glad you are going to try to get your deserved coverage.. please let us know how that goes, so that others here can understand they too do not have to take "no" for an answer!!! Best
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Would you mind telling me how much does an MRI scan cost in the USA please? I was refused one in the UK and am considering doing it abroad and would like some idea of the prices.
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Accidental ~ I think it depends a bit on where you live in the US. I'm in So. California, where everything tends to be pricier than some areas. I've had 2 this year. The first one (which wasn't very good and actually missed 2 lesions!) was billed at $2,000. My second one (done at a major medical center) was $5370!
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And it depends on whether you are going to pay cash.. if so ask what their discount is because in my experience there is always a discount if you are paying out of pocket and with cash.. I had an MRI several years ago (after a car accident) approx. $2K but was reduced by 20%.. I paid out of pocket so the facility had it's money right away and then was re-imbursed by insurance..
AccidentalTourist: Have you tried challenging the disapproval of MRI? Mri's are used all the time here now, there is always a bit of a complaint but usually they end up paying. My suggestions to you would be to get on line and get all the United Kingdom research about Stage 1 recurrance rates, collateral breast impact rates etc.. anything that supports the potential of a better outcome with MRI - then put your challenge letter together and send a copy to your local authorities (don't know what they are called in UK) the one who's job it is to protect the constituents in your immediate area.. and cc the letter to that person on the original doc "challenge doc". Call their office first and find out if they have a particular form you must fill out and sometimes they will get involved at a local level.. I believe that UK also does tumor boards, if you can get their support and send a copy of their support with your letter you'll have a better chance. It helps to know where you might have to go (logistically) to get a breast MRI, since they aren't as available as say a regular one or a CT.. Good luck it's a fight but I imagine that anyone who has gone through what we have will be able to handle it!!! <warm smile> Best
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Hi Otter. I have LCIS, ALH, and ductal hyperplasia (not atypical), and nothing worse. Weak family history. I went to a Major Institution and they said I shouldn't have screening MRIs (not even one baseline one) because I had 'too much scar tissue'. They said my chance of breast cancer was something between 10 and 60%, but probably much closer to 10%. Then they lost the consult, so I can't even show it to my onc.
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Accidental: I live in Florida and it costs about $2000.00.
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I am awaiting approval from insurance for MRI. I expect they will deny it. My ILC was found on MRI last year after mammos and US were all clear. Yesterday my onc felt'something' in good brest, ordered US (denied), mammo (denied). They finally agreed to do the US ( I waited ALL day for approval) and the radiologist recommends an MRI. So they are putting me in for one. The first MRI took 6 months to get approved! I guess it does not matter if you have BC and a strong family hx (mom, grandma, 3 aunts, 2 cousin) I just pray that it will be approved, soon!
D
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Some how we need to organize a petition do go directly to the governing powers. If each of us has to fight with our individual insurance companies we will not get anywhere. This has to be a legal change that is made so every one can get an MRI done when needed and not have to fight every time one is ordered. Shame on the ACS for supporting the insurance companies. Obviously if we don't fight for ourselves no one else will back us.
The local radiology group I had previously contacted for an MRI refused my payment (cash, credit card, check) as they were sub-contracted by the insurance companies! IMO these insurance companies are out of control and jeopardizing patients lives by refusing to have these tests done. They are dictating medicine (without medical degrees) and contradicting your doctor's orders who has personal contact and knowledge of your medical condition and diagnostic hx!!
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Yup, in some ways it's just a business to them.. that is WHY we have to do this individually and collectively.. if enough letters are received by a senator or congressman then they (doc's) can go back to the business of taking care of us.. pill, radiological site, transfussion site, colonoscopy (which by the way have very recently been treating people with tainted lubricants and giving them disease to save a buck!).. No matter what anyone says the US systems is a mess! But messes can be cleaned up!
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Tainted lubricants??? Would like to read articleon that!
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Well here's one article priz47 but there was another one that wasn't connected to the Las Vegas (back east I believe) a container of motor oil was sent to the hospital in the container of what should have been a silicone lubricant. The hospital didn't discover it until several people has had procedures!!!
http://www.injuryboard.com/national-news/hepatitis-c.aspx?googleid=239684
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