insurance won't pay for MRI

karen_in_nj
karen_in_nj Member Posts: 59
edited June 2014 in ILC (Invasive Lobular Carcinoma)

I was diagnosed with ILC in May 2009, and the mammogram I had four months before diagnosis completely missed the huge 6cm tumor. I was planning to have a prophylactic mastectomy on the other side this summer but am now running into trouble with my insurance company. They will NOT pay for me to have a breast MRI, only mammograms. Given my experience, I don't have a ton of faith in the mammogram. My surgeon won't do the surgery unless I have an MRI first. I get the sense from reading the postings on this forum that many of you have regular MRIs for monitoring. I am going to appeal the insurance company decision next week but am not hopeful that I'll be successful. Does anyone know of any resources that support having someone with a history of ILC being monitored with an MRI rather than (or in addition to) mammogram? I want to go into the appeal with as much ammunition as possible. Thanks.

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  • Medigal
    Medigal Member Posts: 1,412
    edited July 2010

    This is ONE of my greatest peeves!!  I have written to my senators about this because this spiel about Mammograms helping ALL women is crap!  My bc was NOT shown on a Mammo!  Ok, what I would do in your case is to discuss this with your doctor and ask him to send a "Letter of Medical Necessity" to the insurance company explaining your particular situation and why the surgeon won't do the surgery without the MRI.   You can still do your appeal but make sure you know exactly what to put in it or it will just go into the trash can, in my opinion.  Or, they may contact you and insist on a Letter of Necessity from the doctors.  So I would not hold things up but get the doctors involved now.  Your ammunition is the help from your doctors.  They "know" what the insurance companies need them to say to get a test paid for so get them involved.  Best of luck to you!

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  • karen_in_nj
    karen_in_nj Member Posts: 59
    edited July 2010

    Thanks, medigal! Actually, my doctor did put in an appeal, she spoke to the doctor from the insurance company, explained my history, and still they denied it. My appeal is a last ditch effort, I know my chances are slim but I'm not ready to give up yet.

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  • cs34
    cs34 Member Posts: 253
    edited July 2010

    hi central, nj.

    i live in edison. what dr's are you going to???

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  • Sue-61
    Sue-61 Member Posts: 599
    edited July 2010

    Report your insurance company to the division of insurance in your state. I believe there is a second level of appeal process, but not 100% sure. I used to work for an insurance company and know that most don't like to spend money in their members. Good luck, Sue

    Edited to add this link: http://www.state.nj.us/dobi/division_insurance/managedcare/umappeal.htm

    The "UM" stands for utilization management, I believe.....

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  • rreynolds1
    rreynolds1 Member Posts: 450
    edited July 2010

    I agree with Sue but I would not wait to have the MRI.  Many hospitals will make interest free payment arrangements.  Once you win, which I believe you will you can pay it off.  If not you can pay them 20 per mo until it is paid off.  Don't put off your care while you fight.

     Roseann

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  • karen_in_nj
    karen_in_nj Member Posts: 59
    edited July 2010

    Thanks Sue-61 and Roseann for the feedback. I'll definitely keep pushing and report the insurance company, and I will not put this off. I am a teacher and was hoping to have the mastectomy in the summer so I'd be recovered before school starts up again. I never anticipated the insurance being a problem, and of course now I'm worried that if they won't pay for the MRI, then they won't pay for the prophylactic mastectomy either.I do really regret not having a bilateral mastectomy at the beginning. I was pushed into it and I didn't consider that I'd have these insurance issues later on.

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  • Sue-61
    Sue-61 Member Posts: 599
    edited July 2010

    Karen, you're welcome and I think Roseann has given you excellent info, also. I have some info re your rights after a mastectomy but I don't see any info re prophylactic mast. Anyway, here is the link and there are 800#s you can call.......

    http://www.dol.gov/ebsa/publications/whcra.html

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  • Sue-61
    Sue-61 Member Posts: 599
    edited July 2010

    Oh, and I should add that I thought MRI was standard of care and had my doc order one and, due to my dx of breast cancer, the MRI was approved by one of my fellow RN case managers, but I had met my insurance company's criteria at the time. It's a good thing I had the MRI as they found another cancer in the other breast and I opted for bilateral mastectomies. AND the pathology post operatively found a small dcis too. So if I had not had the MRI, I would be continuously having more and more biopsies and treatment. Mammograms are not always reliable. MRIs are very expensive. When does the patient become more important than the price of a test, I wonder. Hence, I decided to take early retirement. I was sick of the company profits being published when I fought tooth and nail for many of my patients to get what they needed. And I will add a big AMEN to that statement.

    KEEP FIGHTING for your right to get good health care. Sue 

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  • mymountain
    mymountain Member Posts: 184
    edited July 2010

    Karen,

    Did you have an MRI between your dx and surgery?  Since ILC is usually slow growing I would think they could use an MRI result a bit over a year old. 

    It sucks that you have to fight to get the testing you need in order to have the surgery.  Why will the surgeon not do the mast without an MRI?  Does it matter to the surgeon if there is active disease in the breast if you are set on having the surgery regardless of the MRI results? 

    BTW,  I have an MRI or mammo every  6 months, and have never had a problem with my ins co, but now at two years out,  I am thinking of discontinuing the MRI.  It's just too stressful.

    Good luck with your appeal

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  • susieQ610
    susieQ610 Member Posts: 30
    edited July 2010

    I had the same problem in Australia when I asked my Dr to refer me for an MRI. For some reason the insurance company would only pay a rebate for women under 50yrs old. With ILC MRI seems to be the most accurate way of both measuring the size of the tumour and if there is any sign of Cancer in the non affected breast.  I paid for my own MRI since I did not want to have Mx on a healthy breast. The MRI showed the other breast to have no disease. This was a big relief even those it proved to be quite expensive.

    Good luck with your insurance company.

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  • karen_in_nj
    karen_in_nj Member Posts: 59
    edited July 2010

    Thanks everyone for the information and support. I've never had an MRI, and the surgeon explained that she wants it because if someone has a prophylactic mastectomy the dissection afterwards is not as thorough as what would be done if they knew there were cancer in the breast, and she is afraid they might miss something.

    I spent half of yesterday fighting on the phone with the insurance company and they won't budge. I'm going to have to pay for the MRI out of pocket. I'd already made my decision about the mastectomy but this just reinforced it - clearly my insurance company won't pay for appropriate monitoring.

    I'll add that my insurance company is Blue Cross/Blue Shield, which I thought was supposed to be reputable.

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  • mymountain
    mymountain Member Posts: 184
    edited July 2010

    Karen,

    Sorry you are having no luck with BC/BS.  I have BC/personal choice and have not had any problems with them so far.  Doesn't it seem crazy that they would have no problem paying for a prophylactic mastectomy, but not an MRI. 

    Also I was just thinking, that maybe a second surgical opinion would be helpful.  If you have never had an MRI, what basis did she (the surgeon)use for the original surgery?  She had no problem doing a mast without an MRI at the time of your dx.  Why would she believe that there may be active disease in the unafftected breast?  If during the surgery the frozen section indicated cancer, an SNB could be done at the same time.  Is she suggesting a full AND in the absence of a dx?  I'm a great believer in second and third opinions, especially when it comes to surgery or removing body parts.  I believe BC/BS will probably pay for a second opinion.  Just a thought

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