Insurance calls MRI "Experimental"!?

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Momcat1962
Momcat1962 Member Posts: 665
edited June 2014 in High Risk for Breast Cancer

I had ADH removed last summer. Just before I had the beginning if an MRI. I couldn't even get half way through because some claustrophobic issues. I went back a week later (with valium) and had the MRI. Well, because the mammo and ultrasound reported as being "clear" (extremely dense breasts), the insurance company won't pay for them; calling them experimental...same thing for my 6 month check up scheduled MRI in June. Anyone else have this problem with their insurance?? Oh....We have Blue Cross Blue Shield, too! 

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  • MelissaDallas
    MelissaDallas Member Posts: 7,268
    edited January 2014

    Momcat, what state are you in? Here is a BCBS Tennessee guideline, but I think they would be pretty much the same in other states. 

    http://www.bcbst.com/MPManual/Magnetic_Resonance_Imaging_MRI_of_the_Breast.htm

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  • cymom
    cymom Member Posts: 54
    edited January 2014

    I can't tell from your post whether this MRI is for diagnostic or screening purposes.  I think that it's common for docs to order diagnostic MRIs when they need to look into a finding.  Screening is different.  MRIs are good for screening high risk women, but are considered "experimental" for screening average or low risk women.  They are expensive, and they have a really false high positive rate, so getting them routinely can mean more followup, more biopsies…  there is a risk here that women are more harmed by MRI screening than helped.  This isn't just coming from insurance companies -- independent panels like the USPSTF have looked at it and don't recommend routine screening with MRI except for the highest risk women. 

    Maybe the docs needs to jigger around with the billing codes or write appeals to justify this as necessary to adequately monitor you, given the history of ADH and dense breasts.  Perhaps this bumps you into the "high risk" category?  Absolutely appeal if the doctor says it's necessary  Don't accept the first answer from the insurance company.

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  • Sistercoyote2
    Sistercoyote2 Member Posts: 38
    edited January 2014

    After my cancer diagnosis, my surgeon required a MRI.  My insurance would not pay for it either.  They put it towards my deductible and I have to pay it myself which sucks!!!

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  • farmerlucy
    farmerlucy Member Posts: 3,985
    edited January 2014

    Momcat - I just had an MRI two weeks ago, approved by BCBS of OK. Maybe have your doc appeal it? BCBS is really confused right now with all the changes from the ACA.

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  • MelissaDallas
    MelissaDallas Member Posts: 7,268
    edited January 2014

    I think based on their rules, at least one, if not both, should have been covered and it was how the doctors office coded it.

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  • Momcat1962
    Momcat1962 Member Posts: 665
    edited January 2014

    Thank you all so much. FarmerLucy, I am calling the insurance company tomorrow and have them tell me why they have it as experimental, then call my doctor. When I asked the facility what the order said she said, "MRI, left breast"...that was all! 

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  • cymom
    cymom Member Posts: 54
    edited January 2014

    I think the doctor needs to fax a written explanation to the insurance indicating why the MRI is necessary for your followup.  Calling the insurance company is a start, but its unlikely to resolve your problem.  The people who answer the phones just read from a script.  They really can't resolve issues that don't fit neatly into a box, and often the answers they give you are wrong (I've just been through this with my own insurance company for another test).  

    Make sure you keep it all in writing.  There is a process you can follow to appeal this with the insurance company a few times, and then, if that fails, you can appeal to the state insurance commissioner.  You'd be surprised how many claims get resolved in a patient's favor this way.  

    I found this online -- these are universal procedure and diagnostic codes.  Maybe this will help?

    http://www.bostondiagnosticimaging.com/webdocuments/BREASTMRIINDICATIONCHART.pdf

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  • Momcat1962
    Momcat1962 Member Posts: 665
    edited January 2014

    Cymom, thank you so much! I am going to call the dr's office today. I will update. TGIF!!

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