B-MRI: any trick to getting them approved?

peggy_j

B-MRI: any trick to getting them approved?

peggy_j

After I finished Tx last year, the plan was for me to have both a mammo and B-MRI once a year, offset by six months. My MO ordered the B-MRI but my insurance has denied the pre-approval. Previously. my MO told me that on my mammo (from Feb) the description no longer said I had extremely dense breast tissue which had been a reason why we wanted the B-MRI; my MO thought that lack of dense breast tissue could make it tough to get the B-MRI approved and it turns out she's right.

My doc's office already appealed and provided more info and was rejected again. The balls in my court for another appeal. Does anyone have tips for getting this successfully approved? Special words to use or ???? I have my planned follow up w/ my RO and BS, so I'm considering talking to them before submitting my appeal, but I may have problems with the timing. My doc's nurse suggested I call my insurance company and ask for a Case Manager.

FWIW, my tumor had been found by a mammo, but just barely. It was just 1-1.5 cm down from the skin and seen at the top view but not the side view (and could have been missed by a less careful diagnosing radiologist). I feel that if my tumor had been in a different part of my breast, it would have been missed. Also, I've heard that scar tissue can make it difficult to see tumors on a mammo. Hence my concern about doing more thorough screening.

peggy_j

I still haven't gotten it approved but am making some progress and thought I'd share info in case it helps anyone. What I've done so far:

--called my insurance company and requested a "nurse case manager" (a one-stop contact point who will advocate for my case). She gave me more info on why the request was denied. (the letter only stated that it wasn't medically necessary.) She clarified that they will pay only if the mammogram can't be read or if I have dense breasts. 

--I called my diagnosing radiologist (the one who read my mammo) and asked him to read it again in light of the fact the B-MRI is being denied. He reviewed it and updated the "findings" to indicate I have dense breast tissue. (as I have for all my past mammograms)

--I've begun an official appeal on the denial. FWIW, the nurse case manager said that there can be (if I want) many levels of appeal, including at the state level (California). The state level appeal is outside the insurance company, so if an insurance company has rules that are too stringent, the state board may override them.

Anyway, I will hopefully know more in 30 days, but wanted to share this in case it helps anyone in their own insurance battles. FWIW, I now have 4 doctors who think I should get annual B-MRIs for my screening. You'd think that's enough. Maybe now with the right magic words, it will be approved. (I'm still open for any tips or encouragement, so if you have tricks on getting this approved, lemme know). cheers! 

akc820608

I am in the same boat.  My BS is 3 hours away, and after my intraductal papillomatosis with mild atypia diagnosis, he didn't think I needed a B-MRI, even with my symptoms getting worse.  My GP, which practices in the town I reside in, wants to do an MRI because she cannot figure out what is causing my symptoms.  They orignially started in OCT 2011 and have only gotten worse.  I've been thinking about going to ER or Urgent Care, just because the past weeks, it seems harder to breathe than in the beginning.  Pretty sure ER will do any test possible, needed or not...

peggy_j

You may be right about ER doing any tests including MRIs. When I had a (unrelated) brain MRI about 5 years ago, there was a delay in getting in scheduled and they said some people walk into ER to get it done. arg. FWIW, I didn't know that BC symptoms include difficulty breathing. I know that clots in the lungs have similar symptoms so it seems worth checking out. Good luck!

FWIW, in my case the insurance seems to be looking for certain key phrases, such as "dense breast tissue." I've had my appeal reopen with the new "findings" from the Dx-ing radiologist. Fingers crossed.