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Insurance company will not cover my MRI

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  • dreamwriter
    dreamwriter Member Posts: 678
    edited April 2009
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    Ya got a point there.

  • AnnNYC
    AnnNYC Member Posts: 236
    edited April 2009
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    jlp -- sounds like your case is a naked example of BCBS just trying to evade cash outflow for as long as possible!  I think 15 years ago, someone would have just called saying "we need this information before we can pay" and speeded up the process a little bit.

  • Lisa68
    Lisa68 Member Posts: 1
    edited April 2009
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    If you are at high risk the insurance company has to pay for the MRI.  You should be able to appeal the claim and the physician may have to submit further documentation of why the MRI was requested.  I have BCBS also and had a MRI 2-26-09.  My claim is still pending but I am confident it will be paid 100% as I am high risk. It may just take some time for them to settle it.

    Good Luck! Lisa

  • healthysofar
    healthysofar Member Posts: 4
    edited April 2009
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    I know an MRI technical specialist very well - the people that install and repair these machines. He told me to make sure the facility you are going to is certified so you can get decent imaging. As with anything, there are good and bad ones and you might as well get one that is good if you have to have one. You have a choice of where to get the MRI done.     

  • Deirdre1
    Deirdre1 Member Posts: 22
    edited April 2009
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    Yes I have been denied and for the same reason.  If you put together a well thought out letter describing any persons in the family that could put you at high risk that will help (any first relatives with breast cancer?).. also include the fact that they are "interferring with the doctor patient relationship" that's actually a legal trigger for them.  Be cordial and complete and send it to you insurance company's challenge center within the time frame allotted and keep a copy, but make sure you cc it to your congressman/women as well.  Not a blind copy make sure the name of your congressman/women is on the bottom of the letter.  Make sure you send a copy of the letter to said congressmen/women.. it's a hassle but it's also a big bill.. I think that will help..  Good Luck

    I have used this and had thousand of dollars paid for by the insurance company when they originally denied them.. 

  • healthysofar
    healthysofar Member Posts: 4
    edited April 2009
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    Another thing to watch out for - BCBS has many different addressess for appeals. The gave me one address in their denial letter, a different address in their phone message, and still a different one is listed on their website.

    Like Dumbledore showing up 3 hours early for a hearing because he already knows they will try to screw him over (if I call to check the correct address I have zero confidence it will be the correct one), I am sending my appeals letter to all 3 addresses (and my doctor, and my radiologist, and my congressman...). 

  • healthysofar
    healthysofar Member Posts: 4
    edited May 2009
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    Update - 1 thorough letter sent to BCBS at 3 addresses did the trick. Thanks everyone for the tips of what to include. Their response letter made sure to tell me about the doctor's credentials that I asked for...curiously they didn't cc my congressman...

  • pkb143
    pkb143 Member Posts: 69
    edited May 2009
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    I had a breast MRI April 8 after having a stereotactic needle biopsy. This MRI was scheduled on recommendation of the surgeon I was seeing at the time. The pathology report after the biopsy came back with a DCIS diagnosis, then the MRI showed other 'suspicious' areas in the same breast. This finding prompted the radiologist to report possible multifocal DCIS and helped me decide on treatment options.

    HOWEVER, my insurance company, Blue Cross/Blue Shield, has denied the initial claim (over $4,800) and is supposedly now waiting on "more information" from the hospital where I had the MRI before they finalize the claim.

  • Deirdre1
    Deirdre1 Member Posts: 22
    edited May 2009
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    Healthysofar:  Great!  We all need to "challenge" our denials!  BCBS may not have addressed the congressman in writing, but you can be sure there was a phone call in the back drop, something you may never be privy too.. but the goal was accomplished and it is a lesson for us all - if the tests you are having are reasonable and suggested by a physician, the insurance SHOULD cover them.. They turn them down because probably 45 - 50% of people won't go any farther than that and that is then money they don't have to spend.. It's a rountine that should be challenged in courts - but in the mean time this will help those of us who need the testing now..  <warm smile>  Best!

  • pkb143
    pkb143 Member Posts: 69
    edited May 2009
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    Deirde, you can bet your sweet bippy I'm going to challenge it if it comes back "DENIED"!

    Hell hath no fury like a woman with BC who's off her hormones.Surprised

  • Deirdre1
    Deirdre1 Member Posts: 22
    edited May 2009
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    Yup we've all been through enough!!! 

  • Annabella58
    Annabella58 Member Posts: 916
    edited May 2009
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    Hi ladies:

    I am a BC BS lady as well, and they do, routinely, deny MRIs.  Have your oncologist write the letter and/or call them, that will do it.

    From you, writing them, it is routine for BCBS to deny 3x, 1st.  I don't know why but that is what a friend in the billing dept. of the the hospital told me.

    Good luck!  This is way too common.

  • sue-61
    sue-61 Member Posts: 262
    edited May 2009
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    Hello, All, I am jumping into this thread. I am a retired nurse case manager for a large health ins company.

    Each State has its own division of insurance and I advise anyone to file a complaint if anything reasonable is denied. There are also laws regarding breast cancer and you can google "breast cancer laws" to get info, state by state, on same.

    Good luck. Most insurance companies are NOT in the business of caring, they are in the business of making money.

  • dlb823
    dlb823 Member Posts: 2,701
    edited June 2009
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    Bumping for new members.  Lots of really helpful information here!

  • pkb143
    pkb143 Member Posts: 69
    edited June 2009
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    update: BCBS finally DID PAY my claim for the breast MRI. and it's a good thing, too....for more reasons than one. Just had a right Mx this week and the path report revealed another area in addition to known DCIS areas. It was invasive BC (although I believe from what surgeon said, it would be called a microinvasion). This area had shown up as 'suspicious' on the breast MRI report.

    I did not have to appeal but it took over 2 months to get paid. At this point, I'm happy it was paid without having to go through the appeal process. I would not have been able to handle doing something like that for some time.

  • RITZGAL
    RITZGAL Member Posts: 1
    edited June 2009
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    I'm so glad you got that cleared up, but it stinks that we have to go through this with ins co's on top of everything else.  My late husband had leukemia and it seems I fought for everything.  One kind soul told me to write my letters first, then have dr write, then if no payment, threaton co with dep't of ins complaint.  Lastly, file your appeal because sometimes you get your last chance with the official appeal.  Then you can actually make that dep't complaint.  Lots of times they will pay so as not to have another complaint registered against them.

  • holtbolt
    holtbolt Member Posts: 302
    edited June 2009
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    Let's help one of the good guys win for once!! Will you help a bc sister by voting today? I know it's off the topic... I hope it's okay to post... :)

    http://www.aeroforceone.com/index.cfm/pk/view/cd/NAA/cdid/1177058/pid/1175576

  • safefornow
    safefornow Member Posts: 1
    edited September 2009
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    Seems like this is a common problem.  Anthem denied coverage for my MRI, which was recommended by the radiologist after I had 2 abnormal mammograms and an abnormal sonography. All the documentation has been sent to Anthem, but they still say the MRI was MERELY INVESTIGATIONAL and not medically necessary!  (Although the DR. explained to me that an MRI was needed to determine whether I might have BC and whether a biopsy should be performed.)

    What was I supposed to do....just live with the worry that I might have BC?   Why does the insurer pay for mammograms if further diagnosis is not covered?  I have engaged a health advocate to help with this, but here it is 9 months since the MRI and I still owe the hospital over $2500 for it.  

    The last denial I got said that the claim was submitted after the allowable time period. I have been battling this since the first denial in January and the Radiology billing company recently submitted an amended claim with a different code.

    I am going to take the suggestion posted on this board and contact the state insurance commission. 

  • JustmeAlicia
    JustmeAlicia Member Posts: 629
    edited September 2009
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    My insurance company denied my dr's request for an mri last year.  Instead a sonogram was done and nothing was found.  Now 11 months later I have breast cancer.  WOMEN fight for the proper testing if you feel the need or your doctors do.  If I would have had the mri last year who knows if I would be where I am right now or at least it would of maybe been a much smaller area.  I am having my BL mastectomy on Tuesday. 

  • Annabella58
    Annabella58 Member Posts: 916
    edited September 2009
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    Alicia:

    MRIs can catch things mammos miss, which is why we need both.  My new cancer was only seen on the MRI, the mammo was fine, as was the ultrasound.

    Your diagnosis as things go, isn't bad...ER+ which is good, as you can take an aromatase inhibitor or tamoxifen, not a bad stage, good grade, and HER2-.  I am very glad to see that you are going for both.  Sure wish I had.  But I will as soon as I am able to!!!

    Good luck to you on tuesday.  Are you going for recon?  Is so, come on over to the recon site and make some more new friends.  We would welcome you.

    Stay strong, as you say, one day at a time.

    xoxoxo

  • JustmeAlicia
    JustmeAlicia Member Posts: 629
    edited September 2009
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    HI Annie ~ yes ER+ is good, I will take the tamoxifen for 5 years.  Not sure what kind of chemo but they are thinking yes on the chemo.  I am afraid once they re-stage everything after my surgery it will be worse.  I am making myself crazy as I am sure many of you can relate!!!  :)  Yes I am having recon done at the same time.  I will come out of surgery with the tissue expanders in.  I am new to this site and just trying to find my way around and get the hang of it.  Will look for the reconstruction area ~  Thanks for the warm welcome !

    xo

  • DR-RICCHIO
    DR-RICCHIO Member Posts: 2
    edited October 2009
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    You can sue your insurance company in small claims court.....I've done it over

    100 times for my patients against the insurance companies and never lost....ever.

    I teach this across the country in seminars. My website is www.getpaidchirosystems.com.

     I'm a chiropractor, but teach Dentist, Medical, etc. how to get paid.

    Once you file against them.....they will call you to settle.

    Dr Ricchio

  • DR-RICCHIO
    DR-RICCHIO Member Posts: 2
    edited October 2009
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    Sue them in small claims court.....you'll win.....I've won over 100 times.

    Had to sue my own insurance company for my wife surgery, they paid before

     I went to court.

    Its great!

  • dlb823
    dlb823 Member Posts: 2,701
    edited October 2009
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    Bumping this older thread for anyone who may need help getting an MRI covered ~

  • murphygrady
    murphygrady Member Posts: 1
    edited October 2009
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    Ladies do not give up...appeal the MRI denial.  I am high risk(sister & mother had breast cancer) & have very dense breasts.  Mammo & ultrasound showed nothing.  I had enrolled in a high risk surveillence program which orders an MRI as part of the program.  First MRI was covered but MRI guided biopsy was denied.  We appealed, got it covered & they found stage 1 cancer.  I am opting for a bilateral mastectomy because they just can't see anything on the mammo or ultrasound with me.

  • Mim
    Mim Member Posts: 1
    edited October 2009
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    I can see this will be a challenge. I have LCIS,dense breasts,multiple biopsies, atypia &family history putting me above the 20-25% risk.Private coverage RegenceBlueSheild. After a denial of my MRI I sent the required Appeal form with support letter from my oncologist. I received a letter stating the services that are not  medically necessary, including routine care are not a covered benefit. So my claim was not paid  and because it is not a covered item the $2000 (each year) doesn't even apply to my deductible.

    I will keep checking for ideas of how to fight them in 2010. I'm really sad to see women with BC even have trouble. I don't think anyone would have these procedures without a medical need. How dumb are they??

  • trishm01254
    trishm01254 Member Posts: 1
    edited November 2009
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    Well I am expecting to have an MRI in Jan since I was dx with LCIS in July.  I switched my health ins at work from bcbs to aetna.  I read online that aetna covers the first mri for LCIS.  I hope that is true, we'll see.

  • bf2009
    bf2009 Member Posts: 7
    edited November 2009
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    The M.A. at the surgeons office called me twice today complaining. She said she tried for 4 hours to get a real live person at my insurance ( I have blue cross) and was unable. That the office was shorthanded and she was not able to do her work due to "this thing with having to get your pre-cert for your MRI"

    and even tried to tell me that my insurance did not require it WHEN THEY TOLD ME THEY DID and I was 100% sure.

    I got soooooooooooooooooooo mad. How incompetant can she be? Is she new or something?

    She not only called once, but twice and even a third time.

    I had to call my insurance FOR HER, the MA at the surgeons office and tell my insurance to call her. My surgeon needs to get rid of that M.A.

    That she called me whining about all her problems is a very bad thing. Sure did make me mad.

    I'm going to call my insurance in the morning to make sure that incompetant faxed that stuff to her.

    I wanted to drive to the surgeons and ask them what kind of show they ran to have the M.A. call me to cry she can't or doesn't know how to do her job... and WHINE TO ME about it.

    I asked to speak to her supervisor and she said there was none but sure going to mention it to the surgeon when I go back how she called me to whine she can't do her job, the office is short staffed and to tell me my MRI did not need pre-cert.

    She must have mistook me for an idiot or something !!!

  • dlb823
    dlb823 Member Posts: 2,701
    edited May 2010
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    Bumping for Evelyn.  Hopefully, some of the tips here will be applicable to your situation.    Deanna