Insurance - Preventative vs Diagnostic MRI

Hi, kt57

"she looked through all the billing codes and found the one she thought would give me my best chance"

Any chance of finding out what that code is so I can try it.

Thanx in advance

Same question as the one form barbara11071 -- I have been advised by my former doc at Sloan Kettering an annual breast MRI as part of preventive care. My new breast surgeon doc agreed (I had to leave Sloan Kettering because my new insurance plan doesn't cover them), but now I'm getting billed almost $1200 for the MRI because they (the hospital) says MRI can only be diagnostic (not preventive), and the new doc's admin says she is submitting the only legally permissible code, which the hospital appears to interpret as diagnostic.

Is anyone able to share a code here, that was used to get your preventive MRI billed as preventive?

i appealed and lost. They covered it but my deductible applied

Aetna considers breast MRI a medically necessary adjunct to mammography for screening of women considered to be at high genetic risk of breast cancer because of any of the following:

1. Carry or have a first-degree relative who carries a genetic mutation in the TP53 or PTEN genes (Li-Fraumeni syndrome and Cowden and Bannayan-Riley-Ruvalcaba syndromes); or
2. Confirmed presence of BRCA1 or BRCA2 mutation; or
3. First degree blood relative with BRCA1 or BRCA2 mutation and are untested; or
4. Have a lifetime risk of breast cancer of 20 to 25 % or more using standard risk assessment models (BRCAPRO, Claus model, Gail model, or Tyrer-Cuzick).

Does this not constitute discrimination against Women?

Here we are in 2018.  Not much has changed in terms of coverage for MRI for patient with BRCA1/2, but I have this thought to share and get your feedback. 

My daughter and I both have the BRCA gene. Doctors prescribed annual MRI plus annual Mammogram (alternating at 6 month intervals) for my daughter.  For me (a man) they prescribed Colonoscopy at earlier age and revisited more frequently than recommended for the general population.

Multiple insurance companies have categorized my daughter's claims for the MRI procedure as "diagnostic", whereas the same insurance companies categorized my claims for the Colonoscopy procedure as "preventive".   They do cover the Mammogram procedure as 'preventive'. 

An insurance rep, when denying to treat MRI as preventive, explained to me that whenever a procedure is undertaken "BECAUSE" of anything, that procedure is diagnostic.   Okay.  Then, why is my Colonoscopy (done before age 50, and more frequently than even those over 50) covered as 'preventive'?   Well, first of all, because it IS preventive, but secondly because there exists a standard procedure code for it.  Apparently there is no separate procedure code for a MRI undertaken for preventive purposes. I am guessing there is a SEPARATE code for 'diagnostic' colonoscopy vs 'preventive', but only one code for MRI, because it was never made a standard for the general population.   In other words, the lack of a second code for MRI is an administrative oversight, since the doctors are clearly following established guidelines for PREVENTIVE measures for patients having the BRCA1/2 gene .

As an aside, let me say this is a big deal because the prescription is to do the MRI every year.  With HSA, the deductible (a high amount as the letter "H" in the acronym denotes) gets maxed out EVERY SINGLE YEAR, due to the MRI.  To make matters worse, last year, the MRI turned up positive, and they had to run a second MRI, and she had to pay for BOTH -- on a modest income, in her case.

Getting to the point:  Does this not constitute discrimination against Women? Is there a case to be made along those lines, especially as reinforced by the disparity between insurance designation an the actual medical guidelines, which have now been in place for many years?