Topic: Ultrasounds

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Posted on: Sep 14, 2010 08:43PM - edited Sep 14, 2010 08:44PM by cdccpa

Posted on: Sep 14, 2010 08:43PM - edited Sep 14, 2010 08:44PM by cdccpa

cdccpa wrote:

I am taking Tamoxifen and also have a family history of uterine cancer.  For this reason both my oncologist and gyn thought a pelvic and transvaginal ultrasound was warranted.  I had the ultrasound done last October. 

A month ago, I just received a bill from my hospital for the ultrasound...10 months after the date of service.  I've been told by the insurance company that it was denied because the diagnosis code used was "routine".  The doctors office told me the code they used was for family history...not sure why that is routine.  The hospital says it took them so long to bill me because the insurance company at first put through an adjustment for the contracted amount (last October) so they assumed it was going to be paid.  Then, June 2010 the insurance company reversed that adjustment and said it had been denied.  Of course, the insurance company is telling me that I am past my 180 day period that I had to appeal because they started that clock running last October...however I had no idea during that 180 days that it had been denied because I was not billed. 

My question is just if anyone has had issues with insurance regarding pelvic/transvag ultrasounds?  I really just want to find out if the insurance company had all the facts to make their determination...I don't think "family history" is really the whole story here.  I don't know if knowing I am on Tamoxifen and that I have a personal history of breast cancer makes a difference?  When I call and try to explain this all I am told is that they denied based on the diagnosis code that was used.  And neither the hospital or my gyn's office are being at all helpful.  I was thinking my next step should be to write to BCBS and ask for copies of what they used to make their determination?  Would they have something that spells out what diagnosis codes are covered and which are not?

Thanks for any words of wisdom! 

Carolyn

Dx 5/14/2008, IDC, Left, 3cm, Grade 2, 0/2 nodes, ER+/PR-, HER2+ Dx 10/3/2018, IDC, Right, <1cm, Stage IA, ER+/PR+, HER2- Chemotherapy AC + T (Taxol) Radiation Therapy Breast Surgery Lumpectomy: Left
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Sep 15, 2010 08:00PM lisaattheshore wrote:

I don't have any wisdom, but I think my reply will bump this up.  I have been watching all my bills really closely because I had something like this happen during one of my pregnancies (more than 15 years ago), unfortuneatly I can't recall how I resolved it.  Hopefully some one will know......

Dx 7/2/2010, IDC, 1cm, Stage I, Grade 2, 0/4 nodes, ER+/PR+, HER2-
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Sep 15, 2010 11:12PM lauri wrote:

I got BCBS to re-look at a miscoded item almost a year after billing date -- kept telling them that either the hospital miscoded or the  insurance input person miscoded.  If BCBS didn't send you an EOB denying the charge, they shouldn't be able to start the appeal cycle clock running. 

Here's how I did it -- went online to the BCBS website where I could look up my EOB and treatment history.  There's a place where you can send in questions and get an aswer in 24 hours.  Also sent letters to BCBS stating what was done on whar date.  You should definitely have them send copies of whatever they used to deny your claim.

For my Trans-vaginal ultrasound, my oncologist referred me to a gyn because of the increased probability of ovarian cancer for ANYONE who has had breast cancer -- no family history.

Good lucik !!!

From the ashes of disaster grow the roses of success Dx 3/8/2006, ILC, Left, 6cm+, Stage IIIB, metastasized to bone, Grade 2, 11/12 nodes, ER+/PR+, HER2- Dx 11/15/2021, ILC, Stage IV, metastasized to bone Hormonal Therapy 11/27/2021 Femara (letrozole) Targeted Therapy 12/2/2021 Ibrance (palbociclib) Radiation Therapy Whole breast: Breast Surgery Mastectomy: Left Chemotherapy AC + T (Taxol) Hormonal Therapy Arimidex (anastrozole)
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Sep 16, 2010 05:03AM lisaattheshore wrote:

Very good information Lauri!  Thanks for sharing!

Dx 7/2/2010, IDC, 1cm, Stage I, Grade 2, 0/4 nodes, ER+/PR+, HER2-

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