MRI insurance approval

kkr · May 2011

This is my 1st time to post. I'm a 1-yr survivor of DCIS, who have been through lumpectomy, radiation & Tamoxifen.

I'm interested in having an annual MRI for precautions, along with semiannual mammogram. I don't trust mammo much since it didn't pick up DCIS. The MRI request by my radiation oncologist to my insurance company was turned down recently.

I'd like to know your successful experiences with this. If you succeeded to get an approval of MRI from your insurance company, how did you do it? What kind of reason is convincing enough? I'd appreciate your input.

KR

Emaline · May 2011

I only had one pre-surgery. My doctor didn't seem to think there would be an issue seeing as I have dense breast and already had a diagnosis of cancer. He submitted all the paperwork and it went through. From what I've read here, it seems that some doctors are better able to get these things done through the insurance companies then others. I don't know why.

I'm with you, I would like to get one yearly. I'm going to see what he says to that.

AlohaGirl · May 2011

I have had an annual mammogram and an annual MRI (staggered 6 months apart) since I completed treatment (other than tamoxifen, which is ongoing). My most recent MRI was yesterday! My oncologist mentioned last time I was there that insurance companies are getting tougher about approving MRIs, but since my mammogram was abnormal (due to scar tissue from surgery and rads), he didn't think I'd have a problem getting it approved. The hospital here doesn't schedule the MRI until it is approved, so presumably they were able to get the approval (or I am in for a rude surprise!). I wasn't involved in the process though.

DiDel · May 2011

have your breast surgeon's office submit the request again. After my diagnosis my twin sister wanted to get one and it did get approved but i think the BS had to pester the insurance company. keep trying to you get it! Good luck!

Diane

cycle-path · May 2011

Does your doctor's office not have someone who will "do battle" with the health ins. company for you? That's really their responsibility if the doctor feels it is necessary for your health.

Sandy105 · May 2011

I could not agree more that it is the doctor's responsibility to advocate for you! He/she knows the medical reasons why an MRI is the only manner in which your breasts may be properly viewed to determine what may or may not be under scar tissue! So, let them know you expect them to call your insurance carrier and to get this approved! Do not accept no for an answer for it is the arong answer!

Well mannered ladies generally get the short end of the stick! Perhaps it is time to be a little demanding!

kkr · May 2011

Wow...I'm amazed with all resourceful answers and great support. Thank you very much, all. It's a long story. First my breast surgeon didn't seem willing. Second, I tried my oncologist, who was sympathetic and willing. However, he kept procrastinating by saying, "let's wait for next mammo..." and also making me do research, which I disliked. We had a little issue, which made me decide to leave him for another oncologist. I definitely will talk to her about this.

Anyway, I'm grateful that my radiation oncologist acted in a flash. I spoke with his nurses, and immediately on the following day, he had his assistants make an MRI request to my insurance company. I don't think it was their fault. We have to keep digging to justify my annual MRI. The scar tissue theory was new to me. I will have a discussion with my folks. Thanks again, all

KR

SJW1 · June 2011

KR.

My insurance company wouldn't approve my MRI the 1st time either. I had to appeal their decision and then present my case in person in front of an insurance board. Now because my life time risk of recurrence is 25 percent, I don't have a lot of trouble getting it pre-approved.

Even though different insurance companies have different rules, if you can get your doctor to say you are high risk also, they will probably ok it. Every state also has appeal procedures in place. You may have to go down that route.

Hope this helps. Don't give up. Keep appealing if necessary.

Best,

Sandie

michelleg1122 · June 2011

I work for a dr and my job is to get insurance approvals for procedures. I have not had a whole lot of experience with breast mri's however what I do know is that most insurance companies do not like to pay for them. The reasoning that I have gotten is that it is not the prefered test ( for a lack of better words). Most PPO plans do not require a prior auth but HMO plans always do. If the test has been denied the office can either submit the additional information that the insurance company is asking for (abnormal mammograms etc) or the dr can request a peer to peer to review. The dr will actually get on the phone with someone from the imaging company that your insurance company goes through and give your case. The problem with the compaines that insurance companies go through for approvals have drs giving a yes or no answer for a speciality that they have no knowledge of ( example: a podiatrist will be the one who says yes or no to your breast MRI) its really a stupid process. Good luck!

soccermom · June 2011

How much do the MRI's ussually cost, if you pay for it out of pocket, does anyone know? I just had to switch to Kaiser and I'm hearing they just plain don't do MRI's for followup- anyhow I want to have my pre-Kaiser BC team handle it as I really don't trust anyone else-

I may try go through the breast center's assistance program for low income patients- I'm sure it's very expensive without insurance covering it-

I'm sure it's going to be a battle no matter what I do- will have to start gearing up now, it is due in Nov.

stage1 · October 2011

soccermom, Have you found out anything about MRI and the cost, and where to go? Where is this low income breast center? I also have Kaiser and I am also in CA. I am afraid that a mamogram for follow up on a, now dense breast, will do me no good. I had my first mamo after surgery and it just reported as being dense. It scares me that something will be recurring that we can't see.

lane4 · November 2011

I'm not sure just how the doctors get insurance companies to approve MRI's, but I think it does have something to do with your level of risk, as swalters stated above. I have an extensive family history, although I tested negative for BRCA. I did have a pre-op MRI and now I am on "high risk screening" with alternating mammos and MRI's every six months. My breast surgeon writes "history of breast ca at age 48, extensive family history" on the MRI order sheet every time. So far, I've not had a problem with insurance covering them.

stage1 · November 2011

thanks, lane4, I do have extensive family history but I am older, 63. But Kaiser does not cover MRI from what I understand, for diagnosis. I think I might pay for one myself.

soccermom · December 2013

I finally got MRI approval through Kaiser and a lot of run around... only to find that it would cost me 500. out of pocket. Something doesn't sound right about that figure, I need to double check. Seems like it costs about that without insurance... all very confusing. I think the reason it was finally approved was because of my original HER-2 pos status I am "high risk". Also have dense breasts and Kaiser will do a DIGITAL mammogram every other year if you are in that category. Not sure why they wouldn't just do that every year. The transition to Kaiser has been hell. Just when I had my follow-up all nicely dialed in with my original team of providers. Kaiser also reacted much more negatively to my BRCA variant of uncertain significance than my original team... they really scared me on that one, talking about having ovaries removed etc. until finally I found one gynec onc at Kaiser who told me I didn't need to do that.

MRI insurance approval

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