Refused for MRI

Heartbroken,

I had the same problem. I had an MRI denied 3 times when I reached the 5 year mark. I fought like crazy, along with my surgeons office. to have it approved, but no luck. I also had awesome insurance. They also claimed that the Mamo/ultrasound was enough. I also get blood work done every year that has my "cancer marker" numbers. That also helps if there is anything suspisious going on.

I ended up getting 3 different answeres on why it was denied. First was not enough of a family history. (I guess having cancer isn't enough), Two, you reached the magical 5 year mark, and third, it's not part of the protocal for breast cancer patients to have MRI's.

I also had to get a biopsy done in March, due to a suspicious mass, thank God it was benign, fibrocycistic tissue, but the hospital where I had the biopsy done, was pushing for an MRI, and when I went to get the referral, my surgeon said to hold off, I would have been denied if I had it done before, since it wasn't cancer.

You might want to put some more feelers out to see if it will get approved since you're not at the 5 year mark yet.

Good luck!!!!

Sorry to hear this. I had a similar situation. All my cancer docs recommended a B-MRI last year (my first year follow up). Insurance wouldn't pay, saying that although I had dense breast, they weren't dense enough. (there is a scale that ranks the density). I appealed and lost. I live in CA and appealed to the independent review board and lost.  I'm considering doing the full-breast ultrasound 6 months after my annual mammo. Insurance won't pay it but it's $200 vs. $5000 for a B-MRI. FWIW, when I was discussing this with my MO I asked, "If I was going to pay for a B-MRI out of pocket, which year should I do it?" Her thought was year 2 because the goal is early detection. (and, in theory, our risk of recurrence is highest closest to Dx?) Anyway, not sure if any of this is helpful. I feel your pain.

This is serious BS, and it's not just the insurance companies, it's the hospitals.  The new ACS guidelines are clear:  MRI is indicated for high risk women.  They are also indicated in women with dense breasts, however there is no specific recommendation for density grade as far as I know.

The year after I was diagnosed, I had to fight tooth and nail for an MRI.  This made no sense, as it was my oncologist, NOT my insurance. The radiologist explained to me that MRI is extremely expensive for the hospitals, as they do not get compensated for the significant read time required compared to the mammogram.  I pushed, and I got it.  But I know it will be an issue in the future, as just about every woman I know at the five year mark gets cut off.

This clearly will require a huge advocacy effort on our part.  Though the guidelines are widely available, I know the rate of false positives does not incentivize prescribing them, even for high risk women.

Well ladies here is the update - we have to pat thousands for this and it was negative but 6 mths later went for mamo and sonogram and that showed something - so much for mris - I've had it - luckily thank god I was lucky - was benign. Since they got wind of this the insurance said - see you never needed this test and refuse to pay for any of it.

i really can't stand the paternalist medical community deciding for me that i could do without the 'stress' of a false positive.  Glad peggy  j that your doctors recommended you get the testing, while just warning you of the possibility of false positive.

I agree with you that if you can't get coverage for it, you should absolutely get ultrasound alternating six months with mammogram.  That is absolutely what I would do if I had any real breast left to image. 

I've added the automated full-breast ultrasound to my yearly mammogram exam.  http://sonocine.com/

I have to pay out of pocket $300 but at least I get some piece of mind as backup over the mammogram. My doctor simply adds it to my mammography script and I don't have to fight insurance.  It takes about 15 minutes for the prep and scan.

Why would you need 24 additional meds while taking an AI? Of course I look at it differently as Stage IV. The AI's gave me several more years. And I didn't take any additional meds. I guess I'm fortunate that my former employer provides a level of insurance that has not denied me coverage for what has been necessary. I'm so sorry for everyone who must fight for their treatments and tests, like we need that stress.

Chickadee, I am sorry you have stage IV and glad that AIs have helped with no side affects for you. They DO work for some women, just not all women. And the lucky ones who take them are those, like you who they both work for and without side affects.

With my history, I am a candidate for ALL of the side affects of both AI's and tomoxafen, which would require me to take a dozen or maybe more different meds to off-set the side affects. Unfortunately I know way too many women who have these: bone loss and arthritis, insomnia, depression, fatty liver, weight gain, hair loss, heart issues, stroke, brain tumors, other cancers, eye and vision loss or impairment, shrunken, paper-thin, breakable vagina walls so they can no longer have sex or if they do, it's either a bleeding painful experience or they have to use special creams to make it even tolerable (which can also -in some cases- affect your relationships...), loss of energy, personality changes, tremors, cold and hot limbs, sweats and chills, body pain... and there are drugs to offset the drugs that offset the side affects too.

My point is, it's an individual's choice to make with their family and their doctor over their specific advantages or disadvantages of a particular medicine for them. It should not HAVE to be a one size fits all.

In my case, and this was scary because of the pressure to use the AI's is huge, becaseu of the cancer they found, we decided to go another route: I am on a natural form of AI that causes me no side affects. Instead of robbing my body of all its estrogens, it redirects estrogens so that the good ones still work well in me and the bad ones can't. This can be tested and verified. It's still a treatment and, so far,so good, Thank God! But it wasn't the "standard" treatment, so my insurance dumped me as "declining the standard treatment."

I mean, wow, I am healthier, less expensive, working with my MDs, and still needing my tests and recovery treatments and follow-ups.

On the good side with "gold standard" medicine, they now have this genetic test for the tumors, once removed. It determines whether your tumor genes can predict you fit into one of three categories: the highest one means you need chemo, the lowest one means you don't, the middle one is an optional one. Therefore, the "everyone gets chemo" has been shifted to be determined by this expensive (but less expensive than chemo and less traumatic for the woman who chemo would be worse on than be helped by, if at all) test that now spells out "chemo could be a choice for many women." Yea for it!

The problem with many hosptials is that the funding for tests and trials and the establishing of "standard, one-size fits all" treatments are the big money drug companies. What's the right treatment for one woman is not necessarily the right or best treatment for another.

I'm not sure, but there are I believe about two-dozen different types of breast cancers alone. And, as others have pointed out here, dense breasts need tests that can see into them and so on, thus determining whether a woman should have a mammogram, an ultra sound, an MRI, or any combination should be on a case by case basis. IMHO

Medicine is supposed to be a science AND an art.

Peace to all. And health.

I was just denied an MRI this week.  I was dx'd in 2007 with ILC.  The tumor was not seen by mammo or U/S yet it was.... wait for it.... 10 cm+!!!!   ILC is known for being large and hard to find on mammos.  I had a mastectomy on the left breast but kept the right.     Onc has ordered annual mammos and annual MRI's (with 6 months between each) and this year I was denied.  Cigna stated my mammo was crystal clear and no further tests needed.   I haven't appealed yet.  I cried to the insurance nurse who called Cigna and talked to a really nice nurse who she thought would go to bat for me, but it came back denied again.

I meet with my onc next week.  Seriously considering a proph mastectomy on the remaining breast.

I have two first degree relatives with BC and am a five year survivor myself.  My three remaining sisters qualify for am MRI annually but I do not.  I got my doctor to recommend one every other year and my insurance agreed.    I was so surprised to see the bill.  $4700!!  Is this because contrast dye was used in part of it?

Oh Connie, can't believe they're pulling this with you. Like you I went religiously for annual mamos which were all clean until they saw what looked liked something. They ordered an US, which showed a 1.5 cM something. Sent me for a biopsy which showed ILC. Sent me for a MRI which showed it to be 2.5 cM. But when I had my mastectomy, there were 2 tumors, one over 6 cm.

Think we should all get routine ultrasounds instead if mamos, then MRIs next.