Diagnostic mammogram

I'm so sorry you got caught in this insurance trap.  My several diagnostic mammograms were no different than regular screening mammograms as far as I can tell, except I got an "all clear" before I left the office.  But insurance processes them quite differently.

Your insurance should, and probably will, cover the diagnostic mammo but not as a preventative service, meaning deductibles and co-pays apply.  Did your doctor's office intend to code a diagnostic mammo or not?   I really hope your appeal goes through!

It means a one year interval with a normal screening mammogram...not diagnostic. Diagnostic is different due to the magnification and possibly some extra views instead of the normal screening mammo.

 Seems like someone messed up and they are putting it on you to clean up. Your doctor just needs to say that it was coded incorrectly and it will likely get covered. Strange that someone won't own up to the mistake but then again, nothing surprises me these days. So much incompetence! Hugs and hope they fix it for you.

Hi,

I'm in the same boat and am hoping that someone can help who has been through this. I have High Deductible Insurance. Everything except for preventive care comes out of my pocket. I had BC in 2012 so I get 2 diagnostic mammograms each year. (at least for now.) Last year one mammogram was paid for by my insurance and one I paid for myself. This year I've been billed for both.

Shouldn't my insurance cover the cost of one mammogram. (Or at least the equivalent of the cost of a preventative mammogram.)

I understand that it has to be coded as diagnostic, but I'm hoping that there's a way to get the Insurance company to pay for the preventive part. Otherwise, I'll be paying for mammograms for the rest of my life while they're covered for everyone else and that doesn't seem right or fair.

Anyone else have any luck on getting this resolved? Or have a solution? Anyone else have a High Deductible plan and dealing with this?

Thanks!

I talked to my insurance company and they said it needs to be coded as preventive and routine in order to be covered. I asked and unfortunately they wouldn't give me which codes to use. (They said the doctor should know.) I'm currently talking to my doctor to see if she can get it recoded and then resubmitted.

Hopefully they'll get it resolved.

Since its mid-November, anyone know what happens if I don't get this resolved by Dec 31st? Can I still work to resolve in 2015 or do I miss out and it becomes my mammogram for 2015? That's got me worried as well.

Joined breastcancer.org specifically to look for issues like yours. I have not had a BC diagnosis. But, I have experienced the issue you describe with Insurances denying coverage for "diagnostic" mammograms. I don't know, but believe, the insurance company codes or corrects coding for tests, screenings, etc. I believe, but do not know, that this policy of covering older type screenings but denying coverage for digital or diagnostic mammography is one of probably a number of ways the insurance industry is attempting to circumvent those portions of the Patient Protection and Affordable Care Act that address preventative care.

I was sent for screening. Images inconclusive due to tissue density/margins. I was told the image was bad or unreadable because of this density, which could be cancer, but could not be determined. It is common for older women, which ironically, are those women over 40.

I was sent for digital mammography and the staff scheduling that appointment did an excellent job scaring the holy h*** out of me. Got a bill for radiology, facilities, and the visit. Not covered by insurance. Results from images were "image from regular screening inconclusive; no breast cancer worries found through digital."

Appealing may or may not work. I suspect it will not. I did not try because I was pretty sure the ICD-9 or ICD-10 coding would not help my case. Even if it was changed to preventative screening, only one preventative screening is covered per year. A re-coded digital mammography would be the second.

The insurances (Blues, for certain, maybe others like Aetna, United Health, etc) do NOT cover diagnostic tests and procedures under Preventative Health, and only one screening per year for women over 40 is covered. And, two entities stand to profit from this coding and billing practice -- the insurance company and the provider(s). You and I are on a decidedly uneven playing field.

We need lobbyists to convince legislators to address this loophole. As technology improves, the insurance coding and health care laws will not keep up. There is no incentive on the part of Insurance Lobbyists to address this failure to cover breast cancer screening on our behalf -- they are lobbying on behalf of a profit-driven insurance industry. Sorry to sound so negative, but this is my sincere belief and perspective on the issue (having worked briefly in the industry.)

Next time I go to the doctor and he/she refers me for screenings or treatments not covered because of the newer technology or newer medication, I plan on asking if Bloodletting with Leaches is still covered. I did inform my doctor that I would NOT be paying for imaging that is part of preventative health and screenings.

Good luck

I'm having the same issue with my annual mammogram not being covered by my insurance and being billed to me due to large deductible. I was outraged to find that since I have had BC and a lumpectomy, I will forever now need diagnostic mammograms rather than screening mammograms and that only screening mammograms are covered as preventive care by my insurance (Aetna). It's nonsensical that a person with higher risk cannot get required testing paid for as preventive care. I can't believe this is legal. When I get the energy, I plan to appeal. Hopefully I haven't missed my window. I agree that we need lobbyists to close this loophole. I was told by my BS that since I have had BC and surgery, the insurance must now cover anything I want to do with my breasts to make them "right" again, implants, reduction, reconstruction, whatever. So why do they not have to cover annual diagnostic testing? There should be something in the Women's Health and Cancer Rights Act to address this, but apparently, there is nothing.

I have fought with my insurance company every year, sometimes winning and sometimes losing, about charges for my yearly mammogram, and know from discussions with other women that this a common 'rabbit hole' - going for a yearly screening and being told, after the fact, that the mammogram was instead coded as diagnositc. So, chi-girl, which are the codes that worked to have yours properly coded as screening? As the codes are universal, your sharing will allow others to know what to expect.

I am currently going through the same problem:

Had my very first mammogram recommended by my Dr as I am 45 years old . They coded under diagnostic instead of screening as I had a lump but never told me there was a difference for the insurance. I am now stuck with a $460 bill that shouldn't be as no one ever told me what I was going to have done I never even saw the Oder for the exam the drs nurse send it for me and took the appointment.

I had called my insurance before the exam and they said it was 100% covered as I was aloud one mammogram per years.

I am not paying!!!

I had to back for a diagnostic mammogram and sonogram twice within a few years. Both times were due to an area of dense tissue in the same place. My gyn told me that if I continued to go to the same imaging center, they would have record of the previous results and most likely I would not have to go through the diagnostic again. Not true. They saw the same place and again wanted me to go through a diagnostic and a sonogram. Each time they do this I pay upfront for the diagnostic mammogram around $160, get another bill from the hospital for $215 for the sonogram and yet a third bill from the radiologist for $200. Seems like a racket.

Appeal it. We have BC/BS and were charged OON for a procedure. Long story short we had supporting documentation so we won the appeal. I have to have diagnostic mammograms because of a family history. We’ve never had a problem with them paying for it. I have also had a GP recode a procedure. It was for a stress test. It was miscoded to begin with.
Good luck!

Diane