Breast MRI Denied by Insurance

Your doctors can call the insurance provider and ask dor t a peer review. When done those normally get the Mrii approved. Good luck

Certainly do not give up. Their first response is to deny and figure many people will just quit pursuing it. Even after my clinic did the telephone "peer review", approval was not given. I had to file an appeal then brought my case to a committee using their own policy statements which could be found on line. They admitted error but took an extra 10 days to notify me of the authorization. The letter was not mailed until I called to inquire about the decision.

After having the MRI, their next tactic was to refuse payment to the hospital. I waited some months then contacted our state insurance commissioner's office. The law requires a response within 4 weeks. Following my complaint, a check was issued almost immediately. (I requested they pay interest to the providers but that was not done). There also could have been a fine assessed because they withheld compensation for covered services. When companies act in bad faith, the government can be our advocate!

So sorry you are going through this with your insurance company.  I know only too well the frustration having to deal with their stupidity;  I am triple negative, five years out and my breast surgeon had me doing a breast MRI once a year along with six month mammos.  This year BC/BS refused approval of the MRI.  She fought it diilgently for me, having two telephone peer to peer conferences and nope - still would not approve.  Got to hear the reasons why I was turned down in the letter from their three "doctors" ( and I use that term loosely):

1.  I am the only one in my family to have had breast cancer - no family history (guess it doesn't matter that I am the one with the damn cancer); 

2..  Since I never had BRCA testing, they see no value in the test (they refused my BRCA testing as I was 62 at diagnose - didn't matter that I was triple neg to them); and

3.  At this point in time, it would only be merely investigational, so they see no need.

Really frightening when you realize clowns such as these doctors are making the decisions about our lives.  I hate insurance companies.

Wishing you the best, and hoping  you win your fight.

Here's what happened to me and I'm still making payments on the $5,635 bill so that I my credit rating doesn't get ruined.

11/21/14

What should I do if the insurance company won't pay for the breast MRI (which your doctor ordered)?

1. Doctor ordered Breast MRI (for both breasts)

2. I told nurse at doctor's office that I don't want the procedure unless I know it will be taken care of by my insurance company.

3. Response from doctor's office: Procedure will be covered as long as the insurance company received a letter of medical necessity. The doctor's office submitted said letter to the insurance company. (Note: One of the components of "medical necessity" is that there has to be a history of breast cancer in the family. My mom died from breast cancer in 1992. And, I have dense, fibrous breasts, which make it difficult for the doctor to make an accurate diagnosis through mammograms.

4. I had breast MRI

5. Breast MRI was denied and I am stuck with a bill for $5,635

6. I contact doctor's office and they submit a letter of appeal

7. Insurance company denies doctor's appeal

8. Insurance company requests copy of all of my medical records

9. Doctor submitted my medical records

10. Insurance company still denied payment

11. I filed a complaint with the Illinois Insurance Board. They determined they couldn't be involved in the case or assist me in any way since the insurance company was based in Ohio

12. Illinois Insurance Board submitted my case to the insurance board in Ohio.

13. Reply of Insurance board in Ohio was a copy of the original denial letter from the insurance company

All the while these steps were taking place, I continued to contact my doctor's office for their help. This was continually put back as my responsibility to take care of. I also was in contact with the billing department at the hospital where the breast MRI was done. Although a doctor in their hospital issued the diagnostic procedure and they told me it would be approved, the billing department staff kept telling me it was my responsibility to pay the bill. Yes, they offered a discount only if I would pay $3,000 in full. I was and am still not in a position to pay that amount at once. Even though I had been in communication with the hospital's billing department, the insurance company, and the doctor's office, my account was sent to collections. So that my credit rating wouldn't be gravely affected by this, I continued to pay monthly payments.

In the past several months, I have told people I know about this situation. Everyone I have talked to (including medical personnel) about this in recent months have indicated that I should not have to pay for the breast MRI. I agree.

Talking about this issue again has given me new courage to fight for a refund for what I have paid so far and for the hospital to zero out the balance of the remaining amount on the bill.

I have since contacted my doctor's office and spoke to a nurse who wasn't working at the doctor's office at the time of when I had the breast MRI. I have written one letter to the doctor's office, the hospital billing department, and the collection agency. She agrees that I should have to pay for the procedure and has agreed to review the letter. I am grateful for that. I also asked her to reassess the codes that were used for the diagnostic procedure and that it may make sense for the doctor to have a peer-to-peer review (again) with a doctor at the insurance company.

However, I am hoping I don't get lost in a perpetual loop of phone calls and finger pointing like what happened before.

I am realistically optimistic that I will get my money back.

I am writing here to share my experience and to ask if anyone else has had any success with getting their insurance company to pay.

Thank you for listening.

JulioAnn, Fight on sister! For all that come after you as well as for yourself. Those bureaucrats should walk a mile in our shoes before they DENY any test that is necessary. This is freeking cancer for pete's sake! Hugs and prayers that you prevail! STAY STRONG!