Insurance refusal to pay CAD reading of breast MRI

jillj
jillj Member Posts: 28
edited January 2019 in Employment, Insurance, and Other Financial Issues

Hoping someone one here has some tips for getting my insurance to pay for the CAD reading portion of my latest breast MRI.  Seems they consider that it is not "proven" and therefore disallowed reimbursement.  I want to resubmit the charge but do not know what information to include to get them to re-evaluate it.  Anyone else run into this issue that can offer some help?

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  • peggy_j
    peggy_j Member Posts: 1,700
    edited July 2012

     the CAD reading portion of my latest breast MRI.

    What is this? FWIW, with the few MRIs I've had, they all had to be pre-approved before the MRI center would even book the appt. So did your insurance authorize the MRI (and "standard" reading) but not this CAD reading???

    Based on my own issues with my health insurance company, I think your logic is right. If they deny your claim, you may need more info so the appeal has a chance of coming to a different outcome. My MO's nurse suggested I call my insurance company and ask for a "nurse case manager" for my issue. I got one. She was able to read the report and tell me why my MRI was being denied and it what circumstances it would not be denied. So that person may give you more info. In CA, there are many levels of appeal, and at the top, it is appealed to a state group that's outside the insurance company. So, if the insurance company thinks it's not a proven technology, your internal appeals might keep getting denied and you might hold out and hope the state group has a different opinion. Maybe you'll want to provide data and reports showing it's a proven technology. Does your referring doctor think so? Is he/she willing to go to bat for you? 

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  • jillj
    jillj Member Posts: 28
    edited July 2012

    Hi Peggy-  Yes, the MRI was preauthorized and approved, but apparently the use of CAD (computer aided design) software technology to aid in reading the MRI required a separate pre-auth that was not obtained.  The technology helps pinpoint areas in dense breast tissue (which I had--now since removed!) that need to be targeted more closely by the radiologist.  It's basically a tool for them to help them do their job better.  I guess I am annoyed that it was not preauthorized in the first place and now I am left to deal with the freaking insurance company.  I think I will take your advice and use my case worker with the insurance company to try to get this resolved.  That's a great idea.  Thank you.

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  • peggy_j
    peggy_j Member Posts: 1,700
    edited July 2012

    Wow, that's crummy. How are we supposed to know all this stuff (that there need to be two special pre-authorizations)? I don't blame you for being annoyed. I would be too (and in fact, I'm feeling annoyed just thinking about it, because I'm still in the midst of getting my own B-MRI approved.) Anyway, good luck with that. Hopefully the insurance will come through. If they really fail you, at some point I wonder if the provider should be left holding the bag, since they seemed to drop the ball on the pre-approval process. (but, hopefully it won't come to that...) Good luck!  May the force be with you (as you battle these claims!)

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  • proudtospin
    proudtospin Member Posts: 5,972
    edited July 2012

    I have had tests that needed pre-approval but that was always handled by my docs and the place doing the test, required the paperwork to support it.

    actually, couple of years ago, my PCD ordered a test, contacted insurance for the preapproval before telling me about the test!  Then got mad at me as I was asking questions on why it was ordered.

    I would yell at the docs!

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  • lopsided_blogger
    lopsided_blogger Member Posts: 100
    edited July 2012

    My old healthcare place always had a charge like this for some technology that the insurance co wouldn't pay--it was always like $60, and it happened on ultrasounds and MRIs. I called the healthcare place and just said they didn't give me a choice if i wanted it or not and since insurance won't pay for it, they need to take care of it themselves or talk with the insurance company about it. After they wrote it off the first time, I told them they paid for it before and needed to do it again each time. A huge pain, but at least I didn't pay for it.

    Good luck!

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  • jillj
    jillj Member Posts: 28
    edited July 2012

    Well I learned a bit more Friday.  It is considered by the insurance company as "unproven" technology (which from all I have read is bullshit) but the place I got the MRI didn't tell me that, and didn't give me the option to not use it either.  So both sides are pissing me off! :)  Anyway, I'm glad they used it, but not glad I have to pay the $387 for it.  So I called my health care company case worker as Peggy suggested and hopefuly she will help me figure out what I need to provide them so that they reconsider paying the charge. 

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  • BikerLee
    BikerLee Member Posts: 355
    edited July 2012

    if the insurance route continues to fail... consider talking to someone at the MRI center.  sometimes, they will at least reduce the cost of the bill.  and good luck!

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  • Cindyl
    Cindyl Member Posts: 1,194
    edited July 2012

    For next time... make sure you talk to the insurance filer at your drs office and any imaging places etc.  Tell them up front that they need to make sure any pre approvals needed are done, because you are not authorizing any treatment that the insurance has not approved.  (Email is great for this)  Tell them that if they want to do anything that is not approved by the insurance they need to explicitly get your approval or you will not pay... Then make sure you read the forms they shove at you to sign ...

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  • kkatz
    kkatz Member Posts: 1
    edited January 2019

    I know this is an old post, however, I am now going through the same appeal process but for the amount of $8,000!!! I am requesting a letter from my doctor to give them her input and why she felt it to be medically necessary, but I'm wondering whatever came of your claim?

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  • edwards750
    edwards750 Member Posts: 3,761
    edited January 2019

    kkatz - my husband and I had an issue with BC/BS about a procedure that he needed to have to see if he had Parkinson's Disease. Only one hospital in town did the test and they were OON. The neurologist failed to request an exception with BC so they charged us as an OON charge for $5k+$3k just for the meds to do the test.

    I talked to a BC person who told me if the neurologist had done her due diligence and requested an exception we wouldn't have been charged as OON. We had already met our out of pocket expense at that point for in network. In addition the hospital should have called us we would be charged OON. Plenty of incompetence to go around. The lady at BC advised filing an appeal.

    I wrote the appeal and we won our case. In fact the hospital wrote off the balance.

    My advice would be to be persistent and document everything. Take it as far as you can with whomever. $8k is a lot of money.

    Diane

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  • Moderators
    Moderators Member Posts: 25,912
    edited January 2019

    kkatz, that's really tough. Are you getting help with that? We truly hope it all comes through.

    In case this is helpful, we're giving you this link: managing health insurance after a diagnosis.

    Please keep us posted.

    Warmly,

    The Mods

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