Topic: How to ask insurance for prior authorization.

Forum: Employment, Insurance, and Other Financial Issues — Employment, insurance, and financial concerns are common. Meet others here to discuss and for support.

Posted on: Jul 2, 2017 07:37PM

Posted on: Jul 2, 2017 07:37PM

Queenofshoes wrote:


I had my biopsy. It came back b9 which is wonderful. I had my mri after my biopsy as my doc said because I have extremely dense breadts and my left breast is full of calcifications and very high risk this was the next step.

So I then had my genetic counseling. Very High risk for breast cancer. She recommended preventative mastectomy with reconstruction, or 5 year tamoxifen, or do the mri mammogram circle every 6 months (mammogram then mri every 6 months). however because of my life insurance telling me I would be dropped if I was positive brca I did not do the blood test but based on my consultation I'm at 60% risk of having mutations. My genetic counselor was wonderful.

I have talked with my physician and meet with my breast surgeon and plastic surgeon Monday to discuss pmx and recon.I have checked and my physicians and hospital are in my insurance network. So far everything seems ok there as being in network but not sure it will actually be covered by my insurance.

I have so many emotions right now. I've been so damn scared and frustrated with waiting for the biopsy the mri the counseling. I know I can't keep doing this every 6 months for the rest of my life. I know how fortunate I am that this far everything is b9 but with my history and my family history it's a matter of time. I'm afraid my insurance will deny everything and then my husband has that horrible money burden but he said not to worry we would figure it out.

Has anyone else had these feelings? I have been reading and these boards are wonderful. I know what I need to do but is there any specific wording I could use to help get the prior authorization for pmx I have anthem bc/bs wisconsin

Thanks every one

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Jul 2, 2017 07:42PM kira1234 wrote:

From what I'm seeing insurance should cover. I'm sure they have already gotten the okay.

Dx 6/2010, ILC, Left, <1cm, Stage IA, Grade 1, 0/1 nodes, ER+/PR+, HER2- Surgery 7/8/2010 Lumpectomy; Lumpectomy (Left); Lymph node removal; Lymph node removal (Left): Sentinel; Lymph node removal (Right): Sentinel Radiation Therapy 8/3/2010 Hormonal Therapy 10/5/2010 Aromasin (exemestane) Dx 2/2017, ILC, Left, <1cm, Stage IA, Grade 1, 0/2 nodes, ER+/PR-, HER2- Surgery Lymph node removal; Mastectomy; Mastectomy (Left); Mastectomy (Right) Hormonal Therapy Arimidex (anastrozole)
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Jul 2, 2017 07:46PM - edited Jul 2, 2017 07:50PM by Artista928

I would think your surgeon offices would get the pre-auths. I don't know many who don't do that for you. Ask them. If they are the very very few who leave it to you then you'll need to get the ICD-10 code(s) and CPT code(s). ICD-10 is the diagnosis code(s) and CPT is the procedure code(s). Let us know if they are making you do this. I'd fall off my chair if they don't do it for you. I used to do it in the surg practice I worked for as the surgery coordinator. It's a courtesy. The surg's billing depts also don't want headache of not receiving payment because no auth was completed so to be sure, practices do it themselves. Also many medical systems nowadays have an area where you enter the auth #, and there is always an auth # unless it's Medi-Caid/Medi-Cal or Medicare. So call and ask.

Dx'd at 50. Doing it all, all by myself. Stopped Letrozole after 5 weeks. Debilitating se's. Back on Tamox now. Dx 6/2/2015, IDC, Left, 6cm+, Stage IIIA, Grade 3, 1/4 nodes, ER+/PR+, HER2-, Surgery 8/6/2015 Lymph node removal: Left, Sentinel; Mastectomy: Left; Prophylactic mastectomy: Right; Reconstruction (left): Tissue expander placement; Reconstruction (right): Tissue expander placement Chemotherapy 11/3/2015 AC + T (Taxotere) Radiation Therapy 5/2/2016 Whole breast: Breast, Lymph nodes, Chest wall Hormonal Therapy 6/28/2016 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 12/9/2016 Reconstruction (left): Silicone implant; Reconstruction (right): Silicone implant Hormonal Therapy 2/14/2017 Femara (letrozole) Hormonal Therapy 3/26/2017 Tamoxifen pills (Nolvadex, Apo-Tamox, Tamofen, Tamone) Surgery 9/1/2017 Reconstruction (right): Fat grafting, Silicone implant
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Jul 2, 2017 08:15PM gb2115 wrote:

Yup surgeon's office should do this for you. When you meet with them be sure to ask. They can run the insurance and it will be easier for them to do it.

First Dx IDC in 10/16 at age 38, stage 2A, 1.2 cm ER/PR+ Her2-, Grade 2, 1/3 nodes. Lumpectomy + radiation + tamoxifen. Second Dx IDC recurrence in original location 5/21. 1.3 cm ER/PR+, Her2 -. Grade 2. 2/2 nodes. UMX + AC/T + Zoladex/Exemestane + Zometa.
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Jul 3, 2017 08:31AM Queenofshoes wrote:

thank u all. Seeing surgeons today. Have a good day all.

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Jul 7, 2017 11:55PM vlnrph wrote:

Queen of shoes 👠 what a great screen name!

When my MRI was denied by the company you mention, I filed a grievance/appeal, found a description of the policy parameters on their website then had to go to their local office and appear before a committee in order to point out their error. Since my radiologist had ranked me Birads 3, I was entitled to a six month instead of annual follow-up. They dragged their feet in informing me of their approval, then refused to pay (in addition to causing a 60 day delay in the timing of the scan!)

After attempting to get the billing situation resolved for half a year, I finally made a complaint to our state insurance commissioner which resulted in the hospital being compensated promptly. Also, they were assessed a fine in the form of interest on the amount. My point is, don't give up. They make money by not providing benefits for which you probably have coverage. Your doctor's staff should be able to help so perhaps your experience will not be anything like mine. Let us know how it goes.

Dx 3/7/2011, ILC, 2cm, Stage IIA, Grade 2, 1/25 nodes, ER+/PR+, HER2-

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