Not diagnosed-waiting for approval to get breast MRI -HELP

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EAD1991
EAD1991 Member Posts: 11
edited October 2018 in Not Diagnosed But Worried

Hello. First time posting! About two months ago I noticed a lump on my right breast. I have 1 ultra sound and 2 mammo. Both came back clean but showing extremely dense breast tissue. The breast surgeon put me on anti biopics to rule out mastitis. Finished them and my symptoms are still there. Lump has grown. 2 1/2 weeks ago my doctor submitted a predetermination to my insurance for a breast MRI. Which is supposed to take 24-48 hours to show up on bcbstx. Well my insurance stayed they never got one even though my doctor got a confirmation. They resubmitted again last Wednesday and again my insurance sees nothing. I don’t know what to do at this point. Anyone struggled with this?

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  • EAD1991
    EAD1991 Member Posts: 11
    edited July 2018

    it’s so frustrating how man BCBSTX say that they have not submitted anything when they have 2x now!!!!! I have also had nipple discharge, redness of the breast tenderness up into my armpit lump is pretty big. I just don’t know what else to do.!

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  • gb2115
    gb2115 Member Posts: 1,894
    edited July 2018

    Do you have a copy of the confirmation that the doctor got, or did they get a verbal ok from the insurance?

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  • Georgia1
    Georgia1 Member Posts: 1,321
    edited July 2018

    Good morning. One next step would be to look at your insurance company's website, fine the "appeal" information, and contact them. And if you get insurance through your employer, ask your HR department if you have patient advocate services. You can also look on the website of your Secretary of State; often they regulate insurance and have a consumer health line.

    Best of luck and best wishes to you.

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  • EAD1991
    EAD1991 Member Posts: 11
    edited August 2018

    so my breast mri was denied. And my doctor is trying to set up a peer to peer. So stressed. My right breast now is flat above the nipple and below the lump. Almost indented? I called and left my doctor a message today’s updating them.

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  • MiaMay
    MiaMay Member Posts: 52
    edited August 2018
    Any update, Georgia?
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  • santabarbarian
    santabarbarian Member Posts: 3,085
    edited August 2018

    Is there a patient advocate that can fight w insurance for you??

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  • EAD1991
    EAD1991 Member Posts: 11
    edited August 2018

    still no luck at all. It’s been almost 5 months since I found the lump. My insurance keeps saying they need documentation saying my ultrasound is uninterruptible. But it was negative. But I have a palpable lump, nipple discharge. My Mother was diagnosed with ovArian in early 20s. My doctor gave me anyiobiotics to rule out mastitis. No positive change. Then a couple of weeks ago I noticed my right breast (under my lump and above the nipple) became flat. And now goes inward. I have dense breast tissue. I can’t seem to ever get ahold of my doctor. Last time I did speak to them they told me they have had to reschedule the peer to peer multiple times. In the original request my doctor sent her was extremely clear that he wants a breast mri to beable to diagnose suspicion of breast cancer at an early stage so that I don’t have to get a mastectomy and beable to get diagnosed early to avoid heavy treatment. I just don’t understand this. You think there would be some form of assistance for situations like this for women to beable to go get it done. I call bcbs everyday and ask about updates or anything. I’ve asked for the cradentials of the person who originally denied and they won’t give me that.
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  • KCMC
    KCMC Member Posts: 208
    edited August 2018

    EAD1991: Call your local Congresswoman/Congressman's office - I have two types of insurance military and 9/11, both government and when I was having problems called my local Congresswoman's office and she helped. I realize you probably don't have government insurance but when I was talking to her office they have an advocate who just deals with health insurance companies private and government I was told. Wouldn't hurt to call to see if she or he can do something for you. Good Luck.

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  • EAD1991
    EAD1991 Member Posts: 11
    edited August 2018

    I’m sorry this may sound idiotic but what do I say? Ask to speak to? What can they do? And how do I find the correct number to call?
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  • KCMC
    KCMC Member Posts: 208
    edited August 2018

    Doesn't sound idiotic at all. Here is a link to find your local congresswoman or congressman - just plug in your zip code :

    https://www.house.gov/representatives/find-your-re...

    These people work for you, you elect them into office. I call about all sorts of things, street needed to be repaved, my highway department gave me a hard time she got it done, had a problem with the school board, she took care of it and last but not least the problem with my insurance company. When I called about the insurance company I wasn't sure myself if they could help so when I called I said something along the lines of I am so and so and live on 19 blah blah street within your district. I am having problems with my health insurance company and was wondering if your office could help me.

    Health care is such a hot topic button during election times. Give it a shot you never know, maybe they can help you. I'll keep my fingers crossed and good luck!

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  • KCMC
    KCMC Member Posts: 208
    edited August 2018

    Also one more thing, you will have to give their office permission to speak about your health so as long as you feel comfortable with it you will have to sign a release allowing them to advocate for you if they are willing to do so.

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  • EAD1991
    EAD1991 Member Posts: 11
    edited August 2018
    Does it matter that I live in a different county then where my doctor is requesting services
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  • KCMC
    KCMC Member Posts: 208
    edited August 2018

    No not at all, call the congressman or woman where you reside. That is the person who represents you. My treatments took place in a different county and out of state.

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  • EAD1991
    EAD1991 Member Posts: 11
    edited August 2018

    I called and left a voicemail since it was late. I also forgot to mention this: on 7/18 bcbs wrote a letter to me and my provider stating they need documentation saying my ultrasound was uninterruptible (what! Even my doctor was confused), then on 7/25 a letter saying it was denied due to not being medically necessary and not meeting the guidelines and that it was reviewed by a doctor who specializes in PEDIATRICS!?, then another letter 7/25 again asking for documentation that the ultrasound was uninterruptible.
    Neither myself or my doctor get why they are asking for that. Ultrasound was negative! But I have dense tissue. I can’t seem to find the guidelines anywhere for bcbstx. Or the evicore ones.
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  • KCMC
    KCMC Member Posts: 208
    edited August 2018

    Keep copies of everything take notes and get everyones name. You may be interested in this site too, I personally haven't used their services but a friend of mine did. I believe it is free.

    https://www.patientadvocate.org


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  • Luckynumber47
    Luckynumber47 Member Posts: 397
    edited August 2018

    Can't your dr do a biopsy of the lump without the MRI? That would probably be the next step after MRI anyway and will give you the best answer about what's going on

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  • EAD1991
    EAD1991 Member Posts: 11
    edited August 2018

    that’s the issue! my surgeon won’t go in to go a biopsy blind. He wants a clear visual before a biopsy. My PCP and one other specialists agreed.

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  • Georgia1
    Georgia1 Member Posts: 1,321
    edited August 2018

    EAD, sorry this is still not solved. Did you go to the BCBS website and file an appeal? Also sounds like you need to ask your HR department if you have patient advocate services. You can also look on the website of the Illinois Secretary of State; often they regulate insurance and have a consumer help line.

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  • oxygen18
    oxygen18 Member Posts: 164
    edited September 2018

    EAD, my guess is that bcbs was asking whether the US was uninterpretable, but they mangled that word.

    If your dr certifies that, due to dense breasts, the US is uninterpretable (or not sufficiently interpretable for biopsy purposes), then perhaps this is all that bcbs needs in order to approve the MRI?

    Maybe ask your dr to send the info twice, so they can't claim they didn't receive it, and make sure your insurance ID no. etc. are clearly displayed on the form.

    Sorry you are having to deal with such frustrating red tape, hope it all gets resolved quickly. Best wishes.

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  • EAD1991
    EAD1991 Member Posts: 11
    edited October 2018

    hello everyone! So the fax dropped the page stating I have dense tissue so that was all bcbs needed. My mri was approved I got it done on 9/10. Due to it being 18 days after the first day of my period they wanted me to repeat it. So I did yesterday. The hospital had the report available last night in the online portal. I do not not what the following means. I’m waiting to hear from my breast surgeon. But the report stated this about my right breast:
    So my mri says this about the right breast:

    right breast: There is a 7 mm avidly enhancing mass in the middle depth of the 9:00 breast approximately 3.3 cm from the nipple. This demonstrates rapid initial uptake of contrast with mild washout-type kinetics. It is oval in shape with partly circumscribed margins.

    It said I need to do another ultrasound of that area.

    I wish my breast doctor would hurry up and call me. I called them and the front desk lady said I should hear from them this week.
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  • NotVeryBrave
    NotVeryBrave Member Posts: 1,287
    edited October 2018

    I'm glad that you finally were able to get the MRI done. Hopefully your doctor will be back in touch with you soon. Does the report have a recommendation for biopsy or particular follow up? Or just another US?

    A couple of things that might help other patients in the future: I have called my insurance about problems in the past and sometimes they've put me on hold while they speak to the offending provider's office to figure things out. Also - a "peer to peer" review should not take a long time to get done. And finally - yes, sometimes it's a really small but stupid omission that complicates getting care.


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  • EAD1991
    EAD1991 Member Posts: 11
    edited October 2018

    they just said to do another ultrasound of the right breast.

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  • EAD1991
    EAD1991 Member Posts: 11
    edited October 2018

    I still haven’t received a call yet from my doctor. This is driving me crazy.

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  • Georgia1
    Georgia1 Member Posts: 1,321
    edited October 2018

    Oh EAD I'm so sorry. That language doesn't sound too bad to me so I'll keep sending good thoughts your way.

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