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Medicare coverage of post-reconstruction MRI

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I had bilateral mastectomy with silicone implant reconstruction when I was in my 50’s, and had private insurance. As recommended by my plastic surgeon, I’ve had surveillance MRIs every 3 years to evaluate the stability of the implants. This year I had my first with Medicare, and I received a notice of potential nonpayment when I had it done, and today I received a notice from my secondary insurance that they are not covering.
I have a call in to the hospital billing department to discuss. I’m hoping this was just a miscoding error, and they’ll be able to appeal the denial. Does anyone have any thoughts or advice for my future conversations??

TIA

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  • maggie15
    maggie15 Member Posts: 1,081
    edited July 10
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    Hi @nurse_lizzie , Dealing with insurance denials is time consuming and not much fun. All health insurance providers have utilization management (UM) policies in place. The rationale from the insurer's perspective is that it promotes appropriate medical care at a reasonable cost. From the patient's perspective it can mean not getting medical care that they and their doctor think is a good idea. The reality is probably somewhere in between these viewpoints. UM policies vary between providers and are reviewed and updated constantly so it's tough to keep track of what is current. In my experience I have found it somewhat easier to access the private insurer's UM policies (although imaging and anything expensive like chemo tends to be sent out to another entity with a different name which makes finding info more difficult.) I have yet to find Medicare UMs in an accessible place and the toll free numbers to call about whether a procedure is covered sometimes don't have an answer. I have found Medicare much more up front about what they cover. My private insurance used to dishonestly deny based on my not having one of the particular reasons on their UM document even though I had one or more of the other reasons listed for coverage. I would have to appeal and eventually the denial would be overturned.

    With Medicare your secondary insurance pays if Medicare does. I also have secondary insurance that will sometimes cover what Medicare doesn't but whether they pay in that case depends on their own UMs. If you receive a notice of Medicare potential nonpayment it's a pretty good indication that it won't be covered. From googling I've seen that Medicare does not cover surveillance MRIs for implants. They will pay if there is a rupture, enlarged axillary lymph node or lump present indicating that a recurrence workup or treatment might be necessary. If your doctor can come up with a reason that fits the Medicare UM then it is definitely worth appealing. You can appeal anyhow but you should include medical evidence (research published online in medical journals helps) and a letter from your doctor explaining why surveillance is medically necessary in your case (maybe the life span of the implants has been exceeded or you have an autoimmune condition?) This does not sound like a coding error or having treatment more often than recommended by Medicare, two other things you have to look out for.

    Navigating health insurance can be like walking through a minefield. If your are having any treatment where coverage is uncertain I would recommend getting a cost estimate in advance. The No Surprises Act does not apply to those with Medicare but you know where you stand and you have some leverage in negotiating a lower payment based on the hospital's financial criteria. You can also have the MRI done at a facility where the cost is lower if you are willing to pay for peace of mind.

    Good luck with getting this paid for. I'm not a health insurance expert but I have learned a lot from experiencing multiple denials, filing appeals and having enough of a math/science background to deal with the technical and medical terms.

  • nurse_lizzie
    nurse_lizzie Member Posts: 19
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    Thank you maggie15. I’ve been a long time nurse that worked in jobs that required me to work with many insurance billers, coders, and UM departments. Oh, I know insurances, to be sure! I never had an issue with my private insurance, but being new to Medicare, I was unaware that this wouldn’t be covered. I’ve escalated the issue in the hospital billing department, and have reached out to my PS office. I may try my secondary payer, just to talk to a person who actually knows insurance billing and coverage. I know you don’t get that at Medicare.