MRI Denied -- Any Suggestions?

KPolasek

Since my lumpectomy, chemo and rads, I have had a lot of pain in my breast.  There has been a hard area that continues to grow around the incision area and now it is moving.  Docs kept saying just scar tissue.  But, the pain has been getting to me and I found a new area in August.  My onc office would not schedule me a week earlier to check it, my rad onc was on vacation.  So, I saw my primary care physician (I am on a HMO), he thought scar tissue but referred me to my original surgeon (Dr. Dumbo).  He said it was just scar tissue.  I asked if it could be possible that I might have a cyst .... he said no.

By that time my rad onc was back in town.  I wasn't satisfied with what had been said so far.  I called, he got me in and ordered an ultrasound .... guess what .... radiologist came in the room and said we have found what looks like a cyst (Dr. Dumbo will hear from me at some point) ... and a mass that we are unsure if it is scar tissue or malignancy.  He suggested a digital mamm, or at least a regular mamm and an MRI.  I went to get the mamm .... same thing ...my rad onc offered to order an MRI but I decided to think about it, pray .... and I did. 

I knew that I did not want to go back to Dr. Dumbo if I needed further breast surgery.  So, I found an awesome female breast surgeon and saw her 10/13.  She gave me the best breast exam I have ever had. She measured the mass area.  Also, she said that the cyst is probably seroma.  She said that I definitely need an MRI and so she went forward to get the insurance approval.  They said that it would take a day or two before they would get the approval.  After waiting and waiting  ..... I found out on 10/20 that the MRI was denied.  The assistant who told me said that she was floored that they did.  This HMO has an outside company that reviews cases and decides whether or not tests are approved.  The assistant said that she was re-submitting the request with some re-wording.  Today, I talked to her and she said that there would be a peer to peer review of my case.

What in the world are these people thinking?  I have an aggressive cancer ..... I found out later that Dr. Dumbo did not get an adequate margin in one area .... never mentioned it. 

I am SO MAD!!!!  I am ready to file a lawsuit and I am not the kind that thinks of suing people ....I want the name of the company, the name of the one who denied the request ... and I hope it is a man because I would enjoy making him squirm )  Sorry .... I am really over the deep end tonight.

Anyone else out there had this problem?

Thanks for your input ....

LisaSDCA

Your doctor's office will probably get it through on a narrative report, but just in case they don't get approval - it has been known to work to request a call to the referring doctor by the board-certified MD (surgeon or radiologist) who refused your attending doctor's orders in your specific case. All too often it is just some insurance hack who tries to deny, deny, deny and then see what comes back as worth a fight. Your case is worth the fight, as both your radiologist (based on the ultrasound - did they send a copy of that report?) and your surgeon have recommended it

I know how angry you must feel given the circumstances and your Grade 3 tumor. I can't imagine how Dr. Dumbo missed reporting a dirty margin. GRRRRR! Hang tight - I feel confident that your "awesome female breast surgeon" will go to bat for you.

Lisa

KPolasek

Good morning Lisa,

Thank you for responding.  I just got a call this morning that my breast surgeon's P.A. did a peer to peer review (I guess that is a go to bat for me) yesterday and it has been approved.   I am so thankful.  I have heard HMO stories but have never been a victim until now.  Now, I need to turn my prayers to the breast issue once again.

Thank you!

Blessings,

K

HeatherBLocklear

Oh, Kay, I just read this. When will you know more? Hang in there, girl, we're all rooting for you!

love,

Annie

KPolasek

Hi Annie!

Monday I will have blood work done (to check my kidney function)

Wednesday, 2 p.m., I report for my MRI  (I plan to take some drugs so I don't freak from claustraphobia

I won't see my surgeon until 11/6 (because the rad oncologist will be out for a week .... sigh).

However, I am THANKFUL that this test was approved FINALLY!

Thanks for caring and asking!

Blessings,

Kay