MRI denied

Oh and the thing that got everyone's attention was my visit to the genetic counselor. He gave me a 50% lifetimerisk, and agreed with my decision to have a PBM. Little did we know I already had BC.

Insurance seems to be a necessary evil in life! However - in this case, the decision seems pretty unreasonable. I think that something must have been coded wrong for them to declare both the 3D mammo and the MRI as investigational or experimental.

I had to file an appeal for something else (PCR testing) for my son a few years ago. Most insurers have an appeal process. Mine required that I submit (in writing) why I was appealing their decision. They again denied it. Then I had to do a second level appeal that required supporting documentation. I included a letter from his MD as well as several research papers. They still denied it.

I think that the secret is to get their "bulletin" or statement on when it is considered appropriate. Those can usually be found online or requested from the company. Review that and see if your MD can resubmit so that it definitely is within their conditions. It also may have just been human error - someone filled out something wrong.

Good luck!

Good job on peggy's successful appeals of insurance company denials! I have also done this several times, winning each case. Do not be intimidated, even when they ask you to appear before their doctor & lawyer committee. The only way they make money is to not pay claims...

As NVB mentions above, knowing your policy guidelines is essential. That document may be full of medical jargon and legal terms but you can get help with interpretation from your physician or hospital billing office. A large cancer clinic might also have a social worker on staff to assist with financial issues.

I will bump my earlier post on using your state commissioner's department as a consumer advocate. Although I agree with the observation that prices have come down (usually due to competition from independent, free-standing imaging facilities), paying out several hundred $ is still no fun when more complete coverage exists.

I am a strong advocate of appealing the decision by the insurance companies.

I was given the green light by BCBS when I had the Oncotype test. In 2011 it was $5k. Genomic Labs calls to verify coverage before they conduct the tests. Right after BC approved the test they denied coverage. Go figure. Genomic Labs told me they did that all the time. They would appeal on my behalf. If BC balked I would be charged for the test on a sliding income scale. I never heard from them again. A friend of mine had a similar problem. She was denied 3X but her husband persisted and they won.

My husband was charged OON for a critical test that cost $6k. We appealed and won the case. We were at 100% in network so it was critical that he have the test when he did and be charged in network. It was a nightmare of constant phone calls but I wrote the appeal chapter and verse. The initial doctor fumbled the ball which could have saved us a lot of anxiety and stress. Make no mistake I made sure BC and the doctor were aware of that.

We haven't always won initially. We were charged 3k for a facility fee. Long story but suffice to say BC wouldn't budge on the charge that they said we were responsible for. We never heard from them again which was odd. The hospital never billed us thankfully. This was several years ago. Lesson learned for us. You have to do your due diligence and make sure your doctor, facility, lab charges, etc are all in network. It's absurd to think you have to check off all of this before you have a procedure done. How can you possibly control who the anesthesiologist is going to be for that day? They rotate them all the time.

It's a hassle to challenge the insurance companies but it's more important to not be saddled with the exorbitant costs for medical procedures. We all have more than our share of that with our BC DX.

Good luck!

Diane