Insurance denying biopsy

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TheMissKate
TheMissKate Member Posts: 3
edited January 2016 in Waiting for Test Results

A friend of mine is absolutely terrified, and I am reaching out to try to help.

Her mother has breast cancer, I'm unsure of what stage, and is currently undergoing chemo treatment.

She herself had a mammogram in late December, and it showed a suspicious lump, about 8mm. A following ultrasound showed a second lump, around 6mm.

Despite the findings, her insurance company wants to take a "wait and see" approach, and will not authorize a biopsy right now. They want to wait 6 months, then do another ultrasound.

Naturally, with a direct history of breast cancer in her family, and such a worrisome ultrasound result, my friend does NOT want to wait, but she can't afford to pay out of pocket. She has insurance through her employer, and secondary insurance through the VA. Since her primary insurance is denying the claim, the VA won't take it, either. We live in San Antonio, Texas.

Any advice anyone has would be greatly appreciated.

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  • sheila888
    sheila888 Member Posts: 25,634
    edited January 2016

    TheMissKate .....What the DR is saying ?

    Did your friend appeal ?

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  • TheMissKate
    TheMissKate Member Posts: 3
    edited January 2016

    It would be nice if she would get on here instead of me, but she's... not so much of a reach-out-for-help type, which is why I'm trying to do what I can to seek information.

    I'm not sure what her doctor is saying. Her mother's doctor freaked out, and said she needs the biopsy now. She said she's spoken with the insurance company, and keeps getting a run-around.

    Does she need to get the doctor to push from his end?


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  • sheila888
    sheila888 Member Posts: 25,634
    edited January 2016

    If it was me I would push everybody especially if the mother has cancer.

    For her piece of mind she should do anything in her power...

    I still don't understand the Insurance is denying the biopsy

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  • sheila888
    sheila888 Member Posts: 25,634
    edited January 2016

    please keep us updated.

    Be back later.

    Sheila

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  • MelissaDallas
    MelissaDallas Member Posts: 7,268
    edited January 2016

    I would imagine the insurance is denying the biopsy because it is rated at a Bi-Rad's 3 or below, which is almost certainly benign and no biopsy recommended.

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  • Kicks
    Kicks Member Posts: 4,131
    edited January 2016

    When you say "she has secondary insurance through the VA" - what do you mean? Is she a Veteran and enrolled with VA? If she is enrolled with VA then an appt. with her PC would be in order probably. All of my care is through VA and I get great care - quickly out sourced wehn needed.

    It is great that you want to belp your friend BUT you do not know what is actually going on/was found other than second hand at best.

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  • TheMissKate
    TheMissKate Member Posts: 3
    edited January 2016

    As far as the VA goes, she said exactly that- She has primary insurance through work, and the VA is her secondary insurance. Any claims must go through her primary first, and whatever the primary doesn't pay, the VA then kicks in to help cover. However, in this case, since the primary outright declined the service, the VA won't touch it.

    Trust me, I wish I knew more. Mostly, I'm just looking for a direction to point her in, in order to seek out more help.

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  • Kicks
    Kicks Member Posts: 4,131
    edited January 2016

    So you really have no facts as to what might be going on with her 'insurances' - VA is not an insurance company. Perhaps you mean TriCare which is what replaced Campus - neither are VA.

    Again - she should see her VA PCP. If something is present that needs to be done ASAP - it can/will be. It is possible that TX will be done within VA if needed and is possible to be done at the VA facility or be out sourced locally.

    See her VA PCP.

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