Insurance denial of payment

Irishsweety

On December 6, 2016, I had a BMX. I stumbled across this website during my research, and found it to be an invaluable tool! I was able to find a thread on every topic that I researched. It wasn't until now that I find myself having to put an inquiry out there. My oncologist ordered the Oncotype test and it came back at 23, smack dab in the middle of the middle. We discussed chemo and to be honest, I don't think anybody wants to do it, but I would have if I needed to. My oncologist told me about the Mammaprint test, and we agreed to do that as well. My mammaprint came back as luminal A, which means that I would not benefit from chemo, so I decided not to do it. Yesterday I received a letter from my insurance company denying payment of that test. The cost of which is $8,215, because they consider it experimental/investigational. I had no idea that there was a possibility of it being denied Has anyone had this situation? If so, did you appeal, or did your doctors appeal, and what was the outcome. I feel like I saved a lot of money by not having chemo....don't they see this as a good thing?

gb2115

when I had the mammaprint done I got a letter from Agendia stating if it wasn't covered they would assist with insurance. You might want to reach out to them and see if they will help with an appeal. Mine ended up being covered, but I don't know what happened behind the scenes. That insurance claim took 3 months to go through, so I imagine something might have been going on.

Irishsweety

gb2115 - thank you! I will reach out to them. I'm glad it worked out for you. It gives me hope

SpecialK

PM the member Lisey. She did the exact same - had an intermediate Oncotype Dx so had Mammaprint done - she paid $500 for that. Ask her how it was handled and what she's did. I don't believe she had an individualized arrangement, this is something available to anyone. You might also use the search function as she also posted about it I had Mammaprint done in 2010, and my insurance company denied for the same reason, they deemed the test "experimental", which they don't cover. I had not signed anything saying I would be responsible because this was a biopsy sample, so all that was paid was the specimen prep fee. Good luck!

Irishsweety

SpecialK. Thank you for that excellent information. I will PM Lisey

Lisey

hi all, jumping in here with my experience. I had the mammaprint done after I had the oncotype come back intermediate. This was in July of 2016. In December I got an explanation of benefits from my insurance company saying I owed $9,000. I immediately called up agendia and they were very kind. They told me to just ignore the EOB and wait for them to go through the appeals process with my insurance. If the appeal failed they would then send me a bill for not more than $500. I loved agendia. So far I have not received any other bills. I expect to pay the $500 at some point it just hasn't happened yet. I suggest you call agendia directly they will work with you.

Irishsweety

Lisey - thank you so much! I just called Agendia and they told me the exact same thing. They were very kind and caring. What a wonderful company!!! They did say that it may take some time for an end result, but at least now I can se my mind at ease. Thank you to all of you for your helpful advice

edwards750

Blue Cross did the same thing to me after my Oncotype test. Actually Genomic Labs got their approval on the front end(required) and then BC pulled the rug out from under them. Lady at Genomic Labs(also nice) told me BC did this all the time. She said they would appeal it for me and if they lost they would charge me based on sliding income scale. Never got a bill. BC paid.

Also a friend lost her appeal 2x but persisted and won the 3rd time. It was a $5k charge just like mine. Pretty steep but worth the effort.

Diane

kira1234

I wonder if that's why neither my oncologist nor my breast surgeon ran any testing this time. I know blue cross fought my oncotype test 7 years ago. I was in the gray area then.

Irishsweety

I think it's sad if they are hesitant to run tests that are available, because ultimately they are helpful tools in making decisions regarding treatment. Not to mention that the results from these tests could save on insurance claims. Should be a win win.

Lisey

In my case, having the second opinion of the mammaprint saved my insurance from doing chemo... you'd think they'd pay willingly if it means I don't have chemo. Plus, I'm flat and fabulous... no recon for me. Another $50K saved so they kinda owe me I think. It'll probably take a year or so before I get the bill from Agendia. To be honest, even if it was $9000.. I would have done it. It saved my hair and I avoided poison. worth it.

gb2115

I am so glad that calling Agendia helped!!! In any event, $500 is way better than 8K...and maybe they'll just be able to get it fully covered!!!

The insurance not covering "experimental" things is frustrating. I had insurance balk at part of the costs for my 2 MRIs...I had a $200 copay for each (ok), but then I got slapped with I don't know, $400 or $500 per MRI because they billed for "computer assisted technology" which is apparently considered experimental. I ended up fighting the insurance company, but in the end the insurance convinced the hospital to write the charges off, which I don't think is fair to the hospital either. My issue with their refusal to cover is this: If a scan is $200, then let it be $200. No one, in their cancer treatment, asks the radiologist if they are using experimental technology to diagnose their cancer, lest the insurance balk at paying. No one does that. Who would even think to ask? You go in and get your scan, that's all you do because you want your cancer gone, and you have a copay. Right? And the insurance said if I hadn't signed a paper stating I would pay for uncovered charges, there wouldn't be a problem. But for a hospital, if you don't sign their paperwork (the consent), they generally don't do the procedure. So the patient is stuck.

It still makes me mad when I think about it. They didn't want to pay for my 3D mammograms either, even though I am supposed to have 100% coverage for imaging that isn't major (like CT or MRI) but it ended up being about $30 out of pocket. I remember worrying a lot about that at the time, not having any clue what was coming down the pike....

Irishsweety

I too based my decision on my Mammaprint results and saved my insurance company a bunch of money, you would think they would pay for the test. In my opinion, the test was totally worth it! Some people know for sure that they will do the chemo, and there is nothing wrong with that. I personally didn't want to do it unless I had to, and because I fell into the intermediate range on the oncotype, the Mammaprint was a no brainer for me. Ahhh yes I too remember being concerned about the3D mammogram co-pay....boy was I naive back then.

AMR65

I had a mammogram in 2014 that said I had dense breasts and needed an MRI. I scoffed at it as I had no symptoms and didn't want to pay the cost of an MRI. Then diagnosed with breast cancer in 2016. Now I am REALLY angry that my nurse practitioner didn't advise me to get the MRI back then. My question is--if mammograms are considered screening and covered at 100% per insurance, shouldn't an MRI be also covered at that rate if recommended? If true--then shouldn't my nurse practitioner have known this ?

MelissaDallas

There are screening mammograms and diagnostic mammograms. Diagnostic mammograms aren't free. The MRI would be considered diagnostic-to investigate a known problem

pupmom

My breast MRI was 100% covered.