Insurance - Preventative vs Diagnostic MRI

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kt57
kt57 Member Posts: 425
edited January 2018 in Genetic Testing

I am currently opting for surveillance after bc treatment. I am BRCA2.   My insurance covers 100% for preventative screening services, but does not recognize MRI as screening - so my out of pocket expense is over $1000/year for MRI.    I unsuccessfully appealed the claim arguing it was preventative and should be covered as such.   They said is was billed as diagnostic, not preventative, so I am asking the provider re-bill as preventative.   I doubt that will work.  My last step is to appeal to the State Insurance Comissioner.     Anyone have success in getting this covered as preventative?

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  • kt57
    kt57 Member Posts: 425
    edited May 2011
  • kt57
    kt57 Member Posts: 425
    edited May 2011

    JBin, 

    Thanks for your response. 

    My insurance co doesn't argue that I need MRI, they just don't pay for it as "screening", which is covered at 100%.  They see it as "diagnostic" -- which puts me in the "meet your deductible and then pay 20% of the remaining" category. 

    How is yours paid?

  • Fearless_One
    Fearless_One Member Posts: 3,300
    edited May 2011

    MRI's are always diagnostic, just like PETs, CT's, etc.   I'm sorry you have such a high co-insurance.   Mine is 10%, which would be $700 since MRI's in my city run around 7K.   And I can't even afford that.  

    It's unfair they are diagnosic.   They should be catagorized the same as mammos.  

  • kt57
    kt57 Member Posts: 425
    edited May 2011

    JBin: It would be a long shot, but one worth taking.   My policy says screenings for cancer are covered at 100%, which my MRI clearly is.  Another section says MRIs are covered at 80% after deductible.   When clinical guidelines suggest MRI as screening for high risk people, that should have some bearing.  If all else fails, I may have to petition my employer to add this to our policy, which I really don't want to do - draw attention to it.    I will get MRi, regardless of cost.  

    Fearless:  7K -- WOW!  Almost double what mine are.  I have thoughts of taking on the insurance industry on this one....just have to figure out how.  

    I am still waiting to hear the outcome of the MRI being re-billed as diagnostic,  I got a letter from my clinic saying there was an error in billing and it was re-submitted correctly.   When I was there in March for mammo and clinical exam, the clinic had just sent back the initial ins co payment and re-billed.   When look at my online statements, my co-pay for that MRI has changed to zero...I haven't asked the clinic what's happening on their end  -- and if they got paid the whole amount.   I haven't received a statement from them in a while.    When my provider ordered the MRI for this coming Sept, I told her about trying to get this paid as screening -- she looked through all the billing codes and found the one she thought would give me my best chance.   She could also see where the last one had been coded as diagnostic and then changed to a preventative code.  She ask that  I keep her posted, so she gets it ordered correctly in the future -- I thought that was superb patient care from a busy breast surgeon.  

  • turtlegirl25
    turtlegirl25 Member Posts: 9
    edited February 2013

    I work as an mri tech.  Most imaging centers will give you a cash price for the procedure, if you don't want to use insurance.  Usually around $350-500

  • barbara11701
    barbara11701 Member Posts: 1
    edited November 2013


    Hi, kt57


    "she looked through all the billing codes and found the one she thought would give me my best chance"


    Any chance of finding out what that code is so I can try it.


    Thanx in advance

  • kt57
    kt57 Member Posts: 425
    edited November 2013


    barbara11701,


    Nothing ever worked for me. I have appealed this twice to my insurance company and asked the State Insurance Commissioner to weigh in on the issue. My insurance company does not see this as preventative screening as it is not carry USPSTF Category A or B recommendations, which are the only ones they will fund at 100%. the State Insurance commissioner did said this was a reasonable application of my insurance plan.


    The leaders on the FORCE boards are appealing to the USPSTF Board to add MRI for BRCA and other high risk women as a Category A or B. To get to that category, there must be reliable evidence that MRI will reduce mortality, not just catch disease early. Although if caught early, there is a higher chance of cure. Seems clear to me. We need more research on high risk women.


    Right now my MRI costs around $3500 - I end up paying $1000+ each year. Medicare covers nothing for screening breast MRI. I have a ways to go before I worry about that. I have not researched a "cash-only" option as someone suggested a while back.


    I sometimes think a bilat mastectomy and reconstruction to the tune of $250,000 is the way to go -- my cost would be about the same as the MRI..... Not planning that, but it is a consideration.

  • Mness
    Mness Member Posts: 1
    edited January 2015

    Same question as the one form barbara11071 -- I have been advised by my former doc at Sloan Kettering an annual breast MRI as part of preventive care. My new breast surgeon doc agreed (I had to leave Sloan Kettering because my new insurance plan doesn't cover them), but now I'm getting billed almost $1200 for the MRI because they (the hospital) says MRI can only be diagnostic (not preventive), and the new doc's admin says she is submitting the only legally permissible code, which the hospital appears to interpret as diagnostic.

    Is anyone able to share a code here, that was used to get your preventive MRI billed as preventive?

  • kt57
    kt57 Member Posts: 425
    edited January 2015

    Two have been tried... V10.3  and V84.01   Neither mattered, because of insurance companies have not recognizing MRI as anything but diagnostic.   

  • tbear17
    tbear17 Member Posts: 10
    edited March 2015

    i appealed and lost. They covered it but my deductible applied

  • lbrewer
    lbrewer Member Posts: 766
    edited March 2015

    I had the same issue with mammogram and colonoscopies. Once they have found anything, all other tests were considered diagnostic. Screening only applied if I had never been diagnosed with anything.

  • edmccomb
    edmccomb Member Posts: 1
    edited August 2015

    Aetna considers breast MRI a medically necessary adjunct to mammography for screening of women considered to be at high genetic risk of breast cancer because of any of the following:

    1. Carry or have a first-degree relative who carries a genetic mutation in the TP53 or PTEN genes (Li-Fraumeni syndrome and Cowden and Bannayan-Riley-Ruvalcaba syndromes); or
    2. Confirmed presence of BRCA1 or BRCA2 mutation; or
    3. First degree blood relative with BRCA1 or BRCA2 mutation and are untested; or
    4. Have a lifetime risk of breast cancer of 20 to 25 % or more using standard risk assessment models (BRCAPRO, Claus model, Gail model, or Tyrer-Cuzick).
  • Moderators
    Moderators Member Posts: 25,912
    edited August 2015

    edmccomb, thanks for sharing this information, and welcome to BCO!

  • ww81
    ww81 Member Posts: 1
    edited January 2018

    Does this not constitute discrimination against Women?

    Here we are in 2018.  Not much has changed in terms of coverage for MRI for patient with BRCA1/2, but I have this thought to share and get your feedback. 

    My daughter and I both have the BRCA gene. Doctors prescribed annual MRI plus annual Mammogram (alternating at 6 month intervals) for my daughter.  For me (a man) they prescribed Colonoscopy at earlier age and revisited more frequently than recommended for the general population.

    Multiple insurance companies have categorized my daughter's claims for the MRI procedure as "diagnostic", whereas the same insurance companies categorized my claims for the Colonoscopy procedure as "preventive".   They do cover the Mammogram procedure as 'preventive'. 

    An insurance rep, when denying to treat MRI as preventive, explained to me that whenever a procedure is undertaken "BECAUSE" of anything, that procedure is diagnostic.   Okay.  Then, why is my Colonoscopy (done before age 50, and more frequently than even those over 50) covered as 'preventive'?   Well, first of all, because it IS preventive, but secondly because there exists a standard procedure code for it.  Apparently there is no separate procedure code for a MRI undertaken for preventive purposes. I am guessing there is a SEPARATE code for 'diagnostic' colonoscopy vs 'preventive', but only one code for MRI, because it was never made a standard for the general population.   In other words, the lack of a second code for MRI is an administrative oversight, since the doctors are clearly following established guidelines for PREVENTIVE measures for patients having the BRCA1/2 gene .

    As an aside, let me say this is a big deal because the prescription is to do the MRI every year.  With HSA, the deductible (a high amount as the letter "H" in the acronym denotes) gets maxed out EVERY SINGLE YEAR, due to the MRI.  To make matters worse, last year, the MRI turned up positive, and they had to run a second MRI, and she had to pay for BOTH -- on a modest income, in her case.

    Getting to the point:  Does this not constitute discrimination against Women? Is there a case to be made along those lines, especially as reinforced by the disparity between insurance designation an the actual medical guidelines, which have now been in place for many years?

  • Fab65
    Fab65 Member Posts: 25
    edited January 2018

    Great Point! I will look forward to hearing any input on this topic. I have heterogeneously dense tissue, a strong family history, and ATM (vus) positive( more studies needed to determine significance). My BS has ordered an MRI in addition to my six month follow up Mammo for newly discovered asymmetry. I guess I will find out soon if insurance will cover it. Best of luck to you and your daughter:0

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