Insurance won't pay for follow-up MRIs - Ideas?

Eldub · January 2010

Eldub · January 2010

Had DCIS, lumpectomy, rads. All that a year ago. Surgeon and Onc both put me on a schedule of annual MRIs (and mammograms every 6 months). Had my "1 year later" MRI last month. Just got a letter from the insurance company saying that a breast MRI for someone with a breast cancer diagnosis is considered "investigational" and so not covered by insurance. WTF? They paid for my first MRI, last year - immediately following diagnosis. So, does this mean I'm either out of pocket for annual MRIs, or I disregard the oncologists' recommendations? (Which follow best practices, as far as I can tell.)

I'm sure other folks have dealt with this. What did you do? Did you get insurance to pay, ultimately? Or?

Any suggestions are welcome. Thank you.

Linda

Hindsfeet · January 2010

Linda, you are in a tough situation. I totally understand. It's a crime it cost so much for a mri.

I had to make that call last year when my second surgeon insisted I have an mri, I wasn't for sure if I could pay for it. i didn't want a mri because of added medical cost. My surgeon was glad I had it because they found a second tumor that did not show up on the mammogram. It was my second dx, and I chose to do the mri though a independent imaging company. The bill was cut in half due to self pay and I had to pay for it within a few months.

BUT...my first surgeon, after my first dx, had such tests done at the hospital and not the imaging center. Hospitals usually offer further discounts and will allow you to pay a little every month. Hospitals are more apt to work with you than private imaging companies. Medical tests done at hospitals also offer free services to those who make under a certain amount. I know someone who didn't have to pay anything...hospital wrote it all off. Talk to your cancer doctor, who recommended the mri, to schedule it through the hospital. Hospitals usally don't refuse cancer treatments. My surgeon sees mri's as follow up cancer care.

Also...my primary care doctor said that if she order the mri that insurance and medicare would most likely refuse it...but if my breast cancer surgeon order it ...then it would be covered.

Ask your oncologist to write a letter to your insurance company. This might persuade them to pay it...hope so. I recently paid off the 2007 hospital bills, and I'm still paying on the 2008 hospital bills...I'm hoping they will forgive half of it....if not I will be paying for my hospital bills for another couple of years.

Kitchenwitch · January 2010

Linda, American Cancer Society says on their website that insurers often will cover the cost of an MRI for women who are considered high risk. With a family history, seems like you would fall under that category. If I were you, I'd ask the insurance company again, pointing out risk factors and family history. I hope I don't sound naive -- but I have had great success over the years with insurance companies and providers, not accepting the first denial (or the first bill). I've also had representatives give me different answers at different times. Good luck!

carol1949 · January 2010

Linda, My understanding is when you don't have symptoms, they won't pay for some tests such as MRI. With a stage 0, I wouldn't be too alarmed.

Mammogram missed my tumor at least 2 years in a row. We know that from the growth factors. My onc told me it is like looking for a cotton ball in a cloud. I would suggest to look into thermography. It is probably one of the tools of the future. The Dr. who did my last mammogram said he would like to start using it. It is considerably less money and so far the only draw back is that if it indicates "hot spots", we have no medical tests advanced enough to confirm. You can, however pursue holistic and/or complimentary measures if the thermography indicates anything.

Do some research, I don't think it's as bad as you think.

Deirdre1 · January 2010

MRI's are now a piece of normal follow up in cases of high risk individuals (which you are once you have been identified as having any type of bc and/ore have a strong family history of bc). Insurance companies don't want to use MRI if they can get away with it.. but as barry stated above, have a breast surgeon write the script for the MRI and that should take care of the problem - if not - challenge your insurance company's rejection of your MRI in writing ASAP (there are limits on the time you have to do this). Most people feel that because they are speaking with the insurance company on the phone that is good enough.. Insurance companies on the other hand use this and they know they do not have to accept your "challenge" UNLESS it is in writing. If you have to go to the length of putting this in writing make sure you cc it to your local senate and congressional rep. The laws are a bit muddy on an MRI vs a mammo but if the scrpit is from a breast surgeon and you have challenged you most probably will get an approval. The other way is to pay out of pocket (I know it's a huge expense and risk) and then challenge them - every time I have done this my insurance company has reimbursed me at the lower rates.. but at least I got the majority of my money back as well as an MRI that is incredibly valuable for your health. Good luck Linda!!! (Hi Barry!)

sweatyspice · January 2010

Try having the BS write a letter in support of your appeal to the ins co, stating that the MRI is a matter of medical necessity.

Anonymous · January 2010

Linda---I've been having yearly MRIs (due to high risk from LCIS and family history of ILC) for almost 4 years now. Never got a bill, but recently got a letter saying that a portion of my MRI would no longer be covered as it was "experimental and investigational". I got my oncologist to write a letter stating the medical necessity for it; I have another one coming up in March and I already told his staff to make sure they list on there the reasons for the MRI, so to avoid the problem this year. I think insurance companies are all tightening their belts; we just have to advocate for ourselves to get the tests we need.

Anne

pickle · January 2010

Hi Linda. I was dx last January Stage 2 grade 3. Multifocal IDC and ILC. Left Mx Feb. Finished chemo in June. Went for a mammo and ultrasound on my "good" breast in Sept. Cluster of calcifications so they did a biopsy. B9 and so far so good. The radioligist recommended a follow up MRI due to dense tissues. I had MRI last week, The radiologist (at the cancer center) said that the MRI was fine...no concerns. In fact calcifications don't show up on MRI's. They were really hoping that MRI's wouyld prove to be the best diagnostic tool but she said that has not been the case. She doesn't think it is neccessary and in fact it can give a lot of false positives. She doesn't even do 6 month mammos and is recommending that I only get yearly mammo and ultrasound. She talked to me for about 1/2 hour and I felt very reassured that she knows her stuff. Having said that, I think it is important for you to do what ever is neccessary for your own peace of mind.

Deirdre1 · January 2010

Linda, I forgot to add that it is now common for bs to recommend MRI's every 1-2 years after your surgery especially for DCIS . It was recommended for me, but after my 3 years MRI I plan on going on a much less regimented time table and have one 1 say every 5 years after that - unless something else comes up. The reason I will lax up after three years is because the research shows that if someone is going to have a recurrence with DCIS is very often happens within the first 3 years... I hope you can get your insurance company to cooperate with you!! Best

Hindsfeet · January 2010

pickle 141...what do you mean mri's don't show calification. The mri I had when dx with cancer ... the dcis lit up like a Christmas tree. Wasn't that califications lighting up? How does dcis show up on mri's? I assumed mri's show all cancer. Although I will say that neither the mri or the mammogram showed that I had high grade dcis throughout the quandrant breast they removed.

ok...here's the scarry part...if you are right pickle 141, then the recent mri I had, one year after lumpectomy, showed no calification...therefore no cancer. If califlications don't show up on mri's ... then the mri was useless...?

Great having you back Deidre!

sweatyspice · January 2010

The way I inderstand it, calcifications are the calcified remains of dead cells, they typically show up on mammo and (if they're dead cancer cells) are usually found within the cancerous area (those cells were trying to grow and divide too quickly, they outstripped their food supply, and died.).

MRI shows the increased activity of cancer cells compared to surrounding healthy cells. The live cancerous area will show up on MRI, but not the calcifications within it.

You can have cancerous areas without caclifications (and which therefore don't show up on mammo.). Your MRI was not useless.

pickle · January 2010

I certainly do not want to deem MRI's as useless. They are not useless and have been successful in detecting things that do not show up on mammo/ultrasound. Only your doctor can advise you on it as each person's case is different. I have a cluster of calcifications that showed up on mammo and then they biopsied it. Calcifications when clustered can show cell activity so that is a red flag that should be biopsied. My biopsy was benign. I had an MRI to further investigate due to dense tissue and that I had lobular which is difficult to pick up on a mammo. I am getting a TE expander in the other breast and can't have an MRI with it because it has a magnet in it. They just wanted to have another view in the good breast before my TE surgery. The radiologist said calcifaications don't show up on MRI but if there were other concerns an MRI may help however they don't like to do them as a first line diagnostic tool because they get a lot of false positives. She said it will not be part of my regular yearly screening. It is typically recommended in high risk women to further evaluate after mamm/ultrasound.

If your doctor has ordered any particular test including MRI then they have a reason to warrant further investigation. I would definitely do it.

Deirdre1 · January 2010

MRi's are very expensive so although they are becoming "cutting edge" with respect to breast cancer (as well as other cancers too) the doc's know that more often than not the insurance company will refuse payment (even though I have always been able to reverse that decision with the tactics I mentioned above) so the routine is to comment on how they product "false positives" truth be told all tests have both false positives as well as false negatives.. The tech and radiologists are getting much better at using the information that the MRI produces and my understanding is it is the next best technology for us all.. So with more use and more experience MRI's will become the new mammo's it's just a matter of time IMO... Many doc's try to convince their patients that they (MRI's) are not necessary after a conversation with the genetic counselors at our nearest university (and yes it has a cancer centre) MRI's are our future - so ladies insist that the insurance companies pay for them whenever possible and in the near future the price will also drop too!

Eldub · January 2010

Thank you so much everyone for your concern and suggestions! I really appreciate it.

I finally made a call to the insurance company. I figured this would likely be just a first step, but especially since one part of the letter said "as of January 1st" the procedure isn't covered, and my last MRI was December 30th, it seemed worth it to see if I could at least get this last MRI ($2,101) covered. Anyway, turns out the rejection was not of the MRI itself, but of a $50 additional computer-assisted interpretation of the results. It was THAT "procedure" that was considered "investigational" and therefore not covered by insurance. (I don't know how anyone could have figured that out by reading the rejection letter I received, though.) Further, even that $50 charge shouldn't have been rejected prior to January 1st. The CSR assured me that the MRI itself was covered, and would continue to be covered, under my insurance. Whew.

Now, how often to have MRIs in the coming years is a different question - though I expect to follow the doc's recommendation and do them annually at least for the next several years. I continue to have problems with lymphedema in my torso, and cannot do mammograms while I am having a flare. So the MRIs seem particularly important at times like that (now!) I will also be talking with my BS about other mammogram alternatives - especially ultrasound. Fwiw, I did read up on Thermography as well, and found that it was quite popular in the 1970's but then went out of favor as mammograms became the standard of care. Research at the time gave Thermography mixed reviews (use google scholar to look for "thermography" and you can pull up the studies). I've got an open mind about it (I am open to and do a fair amount of alternative medicine), so am not saying "never." Just not leaning that way for now...

Kitchenwitch · January 2010

Eldub, I'm so glad to hear your insurance company came through! This is part of the education we all go through with insurance. Never assume that "no" means "no" ... Never assume that a bill has to be paid. Providers will bill for the balance of what the insurance didn't pay (illegal; at least in my state - guess you can't blame 'em for trying!). I've had my insurance company counsel me NOT to pay a bill that was submitted after the deadline by a provider. They simply didn't send it to the insurance comapny within the time frame, so they sent the whole bill to me.

And (god bless her) I had an insurance company representative tell me exactly where on their website I could find their guidelines for how a BRCA test could be a covered expense (it was in a place for providers).

I find the insurance/money part of health and illness frustrating but also fascinating. Worst story: I know someone who paid $45K in bills for a hospitalization (over a period of time). She and her husband BOTH have insurance. They're rather simple people. They simply assumed that if someone was billing them, there was a good reason, and they were responsible for paying.

Insurance won't pay for follow-up MRIs - Ideas?

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