MRI denied

Laureneliz

Hi all,

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?

MTwoman

Hi Laureneliz,

Sorry you are having to fight with the insurance company along with worrying over your breast health! there is a forum specifically for insurance types of questions:

https://community.breastcancer.org/forum/113

They may have more information for you there.

The only advice I can give you is basically, fight them. Ask what you need to do to take it to the next level. MRI is NOT considered experimental under several circumstances, one of these is breast density. There will be information that you can provide them, but knowing what kinds of documentation they need will let you be forearmed. Good luck!

mkkjd60

Hello Lauren, Sorry you got denied by insurance for an MRI. All I can say is keep fighting for it. Do you have a family history of BC anywhere? My mom died of bc at 73. She had an aunt who also died of it late in life. I had had 2 benign biopsies. That was enough to get approval for a yearly mri from blue cross blue shield. In my case, the insurance company said that my doctor had to prove I had greater than I think a 24% lifetime risk according to the GAIL model for lifetime risk of breast cancer. Take a look at the GAIL model on line. You can literally plug in your info and get your risk assessment. Good luck! Remember, keep fighting for it!

gb2115

Part of my MRIs (I had 2) were denied, because the radiologist used "computer assisted" technology which they deemed experimental. I was able to get the insurance to get the hospital to write off the part of the charges they didn't cover, but when I think about it, it's not really fair to the hospital. So the regular MRI charges went through, but $600 of each MRI they wouldn't cover.

I know for me there were appeal procedures I could do, but didn't have the energy.

Maybe if your surgeon's office calls the insurance company they can figure out what to do.