Topic: MRI denied

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Posted on: Feb 28, 2017 05:40AM

Posted on: Feb 28, 2017 05:40AM

Laureneliz wrote:

Hi all,

I posted this in the high risk forum but I didn't know there was a forum for insurance questions so here goes.

I got a letter today that my breast MRI claim was denied because it was considered investigational (experimental).

I saw a thread on this but it was old so I'm wondering if anyone has advice on how to appeal this. I was told by the surgeon's office that they got approval for the MRI before they set it up but apparently that didn't happen. I had an excisional biopsy/lumpectomy for ADH and I have extremely dense breasts. The dr. wanted a better look before going in for surgery which was smart but not according to insurance which is considering it experimental.

They are also denying the 3d mammogram too, saying that is experimental as well.

The surgeon mentioned she'd like to maybe see me with the 6 month mamo, 6 month mri schedule so this would be an issue going forward too, unless I get a new job with better insurance than the one my husband has.

My husband's insurance is based out of NC but we live in New England. I am very frustrated right now. Any advice? Should I have the surgeon write a letter or call them?

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Feb 28, 2017 07:58AM farmerlucy wrote:

Lauren - my onc orders yearly MRIs for all her BC ladies. She has to go to the appeal process for most. She said she has to actually get on the phone herself with the insurance decider. Not sure that is of any help to you, but there probably are some tricks the dr or the dr's nurse could help you with.

Seems like approval should be a no brainer pre-excisional biopsy. I had one pre biopsy.

Good luck. Sorry for all the stress. Hang in there.

In the absolute worst case you could negotiate with the MRI provider to pay cash. Here in Oklahoma the cash price is around $800.

Dx at 51 after a preventive mx that wasn't. Oncotype dx 3. 3D tattoos from Vinnie! PTSD?? You are not alone! Surgery 2/21/2012 Prophylactic mastectomy; Reconstruction (Left): Tissue Expander; Reconstruction (Right): Tissue Expander Dx 2/24/2012, IDC, Right, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2- Surgery 3/11/2012 Lymph node removal Surgery 7/22/2012 Reconstruction (Left): Silicone implant; Reconstruction (Right): Silicone implant Hormonal Therapy 4/10/2013 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 4/14/2015
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Feb 28, 2017 08:01AM - edited Feb 28, 2017 08:02AM by farmerlucy

Oh and the thing that got everyone's attention was my visit to the genetic counselor. He gave me a 50% lifetimerisk, and agreed with my decision to have a PBM. Little did we know I already had BC.

Dx at 51 after a preventive mx that wasn't. Oncotype dx 3. 3D tattoos from Vinnie! PTSD?? You are not alone! Surgery 2/21/2012 Prophylactic mastectomy; Reconstruction (Left): Tissue Expander; Reconstruction (Right): Tissue Expander Dx 2/24/2012, IDC, Right, 1cm, Stage IA, Grade 2, 0/1 nodes, ER+/PR+, HER2- Surgery 3/11/2012 Lymph node removal Surgery 7/22/2012 Reconstruction (Left): Silicone implant; Reconstruction (Right): Silicone implant Hormonal Therapy 4/10/2013 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 4/14/2015
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Feb 28, 2017 08:14AM Lovey222 wrote:

Hi...Same thing happened to me & my husband's insurance is also based out of NC and we live in NJ. According to the carrier (BCBS) all of my claims are processed through the NJ provider but I still call the # on my card with any questions.

I also received a denial letter after I already had MRI stating it was investigational. Well I freaked out because in my situation it was a reoccurrence (less than 1 year) and I had an implant. I had biopsy 2 weeks prior confirming reoccurrence and BS, PS & MO wanted additional imaging before surgery as well. When MO ordered MRI there wasn't an issue. I called the office when I received EOB and they told me all they had to do was send biopsy results and it wouldn't be a problem. I know your situation is different but maybe this will help.

All the best, V

Dx 7/2015, IDC, Left, 2cm, Stage IIA, Grade 1, 0/3 nodes, ER+/PR+ Dx 10/2016, IDC, Left, 1cm, Grade 1, ER+/PR+ Surgery Lymph node removal; Mastectomy: Left; Reconstruction (left): Silicone implant, Tissue expander placement Radiation Therapy Breast, Chest wall Surgery
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Feb 28, 2017 08:18AM NotVeryBrave wrote:

Insurance seems to be a necessary evil in life! However - in this case, the decision seems pretty unreasonable. I think that something must have been coded wrong for them to declare both the 3D mammo and the MRI as investigational or experimental.

I had to file an appeal for something else (PCR testing) for my son a few years ago. Most insurers have an appeal process. Mine required that I submit (in writing) why I was appealing their decision. They again denied it. Then I had to do a second level appeal that required supporting documentation. I included a letter from his MD as well as several research papers. They still denied it.

I think that the secret is to get their "bulletin" or statement on when it is considered appropriate. Those can usually be found online or requested from the company. Review that and see if your MD can resubmit so that it definitely is within their conditions. It also may have just been human error - someone filled out something wrong.

Good luck!

TCHP x 6 with pCR. One year of Herceptin. DTI pre-pec surgery. Quit Tamoxifen after 3 months. Dx 11/21/2016, DCIS/IDC, Left, 2cm, Stage IIA, Grade 2, 0/3 nodes, ER+/PR+, HER2+, Targeted Therapy 12/19/2016 Herceptin (trastuzumab) Chemotherapy 12/19/2016 Carboplatin (Paraplatin), Taxotere (docetaxel) Targeted Therapy 12/19/2016 Perjeta (pertuzumab) Surgery 5/9/2017 Lymph node removal: Sentinel; Mastectomy: Left; Prophylactic mastectomy: Right; Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Hormonal Therapy 9/9/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Hormonal Therapy 6/26/2020 Evista (raloxifene)
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Mar 1, 2017 11:01AM peggy_j wrote:

Sorry this has happened. My MO recommended a mammogram and MRI annually, done 6 months apart. My insurance, which was excellent in all other regards (through my ex-husband's employer) denied my MRI. I appealed. I live in CA and went up the chain for the external appeal. My MO did the physician-to-physician review. We even found another angle and tried it again. I think one year my surgical oncologist ordered it. In my case, they always denied the MRI. I've done a lot of insurance appeals and have always won (including paying for the BRCA testing). But this time, no go. FWIW, my mom was Dx'd with ovarian cancer in 2015. Since then, they have approved the B-MRI on the first request. So I guess they look at your overall risk factors. I'm sure your doctors are listing every risk factor they can consider but FYI. FWIW, the price of the MRI seems to have come down. If you choose to pay yourself, you should check out the cost beforehand. Sometimes insurance companies get a negotiated rate. Not sure if you would get that discount for self-pay. My initial one (in 2011) was around $5K. This past fall it was maybe $2600 (I'd have to check). Not sure why the price was different; I used the same insurance company and it was the same 2-step process with and without contrast. I still had to pay a 20% co-pay so it wasn't free but FYI. Best of luck with this!

Dx 2/2011, IDC, <1cm, Stage IA, Grade 1, 0/3 nodes, ER+/PR+, HER2-
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Mar 6, 2017 10:34AM vlnrph wrote:

Good job on peggy's successful appeals of insurance company denials! I have also done this several times, winning each case. Do not be intimidated, even when they ask you to appear before their doctor & lawyer committee. The only way they make money is to not pay claims...

As NVB mentions above, knowing your policy guidelines is essential. That document may be full of medical jargon and legal terms but you can get help with interpretation from your physician or hospital billing office. A large cancer clinic might also have a social worker on staff to assist with financial issues.

I will bump my earlier post on using your state commissioner's department as a consumer advocate. Although I agree with the observation that prices have come down (usually due to competition from independent, free-standing imaging facilities), paying out several hundred $ is still no fun when more complete coverage exists.

Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-
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Jun 5, 2017 01:44AM candles1 wrote:

A note on the pricing of MRI... some machines are more advanced and can detect things to a much finer degree than others. The cheaper (older) machines may not pick up all the things that the newer, more powerful (and more expensive) machines can pick up. My insurance companies have always refused to approve the more expensive machines, but would approve MRI at facilities offering the older machines. Just something to think about, and one of the reasons I opted for BMX when I had the chance. I knew that I could never trust the MRI machines that I was allowed to use to pick up a recurrence at the earliest stage.
Dx 11/8/2016, DCIS, 1cm, Stage 0, Grade 3, 0/3 nodes, ER+/PR+
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Jun 5, 2017 07:11AM edwards750 wrote:

I am a strong advocate of appealing the decision by the insurance companies.

I was given the green light by BCBS when I had the Oncotype test. In 2011 it was $5k. Genomic Labs calls to verify coverage before they conduct the tests. Right after BC approved the test they denied coverage. Go figure. Genomic Labs told me they did that all the time. They would appeal on my behalf. If BC balked I would be charged for the test on a sliding income scale. I never heard from them again. A friend of mine had a similar problem. She was denied 3X but her husband persisted and they won.

My husband was charged OON for a critical test that cost $6k. We appealed and won the case. We were at 100% in network so it was critical that he have the test when he did and be charged in network. It was a nightmare of constant phone calls but I wrote the appeal chapter and verse. The initial doctor fumbled the ball which could have saved us a lot of anxiety and stress. Make no mistake I made sure BC and the doctor were aware of that.

We haven't always won initially. We were charged 3k for a facility fee. Long story but suffice to say BC wouldn't budge on the charge that they said we were responsible for. We never heard from them again which was odd. The hospital never billed us thankfully. This was several years ago. Lesson learned for us. You have to do your due diligence and make sure your doctor, facility, lab charges, etc are all in network. It's absurd to think you have to check off all of this before you have a procedure done. How can you possibly control who the anesthesiologist is going to be for that day? They rotate them all the time.

It's a hassle to challenge the insurance companies but it's more important to not be saddled with the exorbitant costs for medical procedures. We all have more than our share of that with our BC DX.

Good luck!

Diane


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