Insurance denies payment for breast MRI!

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econmom
econmom Member Posts: 73
edited June 2014 in Managing Side Effects of Breast Cancer and Its Treatment

Hi all, I am not sure where to post this, but I am hoping if anyone experienced this, they might have some tips for my appeal.

After my initial diagnosis of DCIS from an ultrasound-guided biopsy, I had a breast MRI and biopsy, finding small multi-focal IDC in the same breast.

After first approving the MRI in late May, the insurance company now sends me a letter denying payment saying the MRI is "experimental?"  WTH?  Isn't an MRI after an initial diagnosis the standard of care?

I hope this is not the beginning of a series of fights. 

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Comments

  • NancyD
    NancyD Member Posts: 3,562
    edited July 2008

    In my experience, anything that my insurance company has "denied", I appealed and it was reversed. I can't say whether an MRI is considered "experimental"...maybe for initial diagnosis, but certainly not for pre-surgery evaluation. So try an appeal and see what happens. It wasn't hard to do but you may have to print out some supporting viewpoints from reliable medical personnel that you find on the web to attach to the paperwork.

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  • Jen44
    Jen44 Member Posts: 631
    edited July 2008

    In my opinion you should also get your doctor to contact them and have them explain why the MRI was necessary.  I know that originally my insurance company denied me getting my ovaries out.  My surgeon called them and then they paid it.  It could be as simple as something wasn't filled right.  I unfortunately have had that happen a couple of times as well.  Try not to panic.  I am sure it will eventually get paid.  It just seems like the insurance companies like to have us jump through hoops from time to time.  Call your insurance company and ask them what the exact reason is for the denial.  Take that to your doctor's office and ask them how they can help you fill so that your insurance company will be satisfied with the necessity of the procedure.  I hope this helps and that everything works out okay.

    Keep laughing,

    Jenny

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  • Emily2008
    Emily2008 Member Posts: 605
    edited July 2008

    Also, if they originally approved the procedure, they can't turn around and deny it, unless there's something I'm not understanding.  I've done insurance/medical billing for years, and while they are usually pains in the neck about this sort of thing, typically there's a series of steps they go through to approve or deny a procedure. 

    Hope it works out! 

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  • vhqh
    vhqh Member Posts: 535
    edited July 2008

    I agree with the others who say to appeal this, your doctor should be willing to help with this.  I spoke with my surgeon about getting a MRI on my "good" side prior to having a mastectomy, he told me that the insurance companies tend to balk at paying for them but then I didn't already have a diagnosis for that side. 

    I had to file an appeal when they denied payment for the anethesiologist for my lumpectomy based on the individual anethesiologist who did it not being "in plan" despite the fact that the  anethesiology group as a whole was "in plan".  17 days later that same individual was "in plan" and they paid for it when she did the port insertion.  End result was that the anesthesiology group wrote it off, insurance flat out refused to pay.     

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  • Shirlann
    Shirlann Member Posts: 3,302
    edited July 2008

    Hi, I have heard that the first TWO requests are ALWAYS denied, and you must just keep pestering them with a thinly veiled threat to contact the State Commisioner of Insurance with a written complaint.

    Just don't give up.  This is ridiculous.  Pester the heck out of them (like weekly letters, they have to sign for, "Return Receipt Requested", and you will get this paid.

    Don't send the letters registered, too expensive and too slow, but this way, they will know you are keeping  file of all the letters of request and ALL THEIR DENIALS.  Get your doc to send one, if he will.

    Don't let them get away with this.

    Hugs, Shirlann 

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  • dhettish
    dhettish Member Posts: 501
    edited July 2008

    Hi,

    My insurance denied only part of my MRI (Computed aided detection) as experimental. That was about a $250 charge. Apparently, I signed to pay for it but the company wrote it off. I do not see how insurance can approve something, you have it and then they deny it. Are you sure they denied the whole thing? Call them on the phone and ask for a nurse manager to see exactly why they denied it. MRI's have been around for a long time and are not experimental. Possibly the CAD was denied. Once you know why, then you can appeal. Ask your doctor why he/she ordered the test and what he/she needed to know from it. The more you understand, the better you can appeal.

    If it is the CAD, from what I have read, this is computer technology that allows the radiologist to spot cancer quickly. Basically, from my research, it allows them to view more films more quickly because the computer shows them suspect areas. There has not been enough research to see if the computer actually finds more tumors than the physician's eye. It is simply an aid for the physician's benefit and ultimately the patients since radiologists read so many films.

    Debbie 

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  • AnnNYC
    AnnNYC Member Posts: 4,484
    edited July 2008

    I really don't understand how they can first approve and then deny.  Also, is it worth pointing out to them that the results support the medical necessity?  The MRI found IDC that apparently was not seen on ultrasound or mammo!!!!  That's the rationale for doing an MRI -- and in your case the results prove the validity of that rationale!

    Like Jen 44 and Debbie/dhettish said, it's a good idea to call the insurance company and ask exactly why it was denied.  This could be a coding error of some kind that a computer just didn't accept -- like, because you already had a breast cancer diagnosis (DCIS) they wouldn't pay for another procedure to diagnose breast cancer -- there's probably a numeral or two that will make it a different code from what they first paid for with mammo/US/biopsy.  (This happened with my plastic surgeon -- they submitted something with a previously-used code instead of code for "follow-up" care. My insurance company told me what to tell the doctor's office to correct and resubmit the claim, and it worked.)

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  • jdg1
    jdg1 Member Posts: 608
    edited July 2008

    I am not understanding how they could authorize it and then deny it as well.  I wonder if they are just denying it for one side.  I had no problem after having my biopsy with my insurance company paying for an MRI of both breasts.  I would definately go back to the Insurance and appeal it.  Good luck to you

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  • TheShopMama
    TheShopMama Member Posts: 577
    edited July 2008

    I was fortunate enough that my insurance company denied my breast MRI before I had it done.  My doctor appealed it via a "peer to peer conference" in which the doc from my insurance co. agreed with him, but it was denied again because it didn't fit the insurance company's protocol.  I am in the process of my own appeal now and hoping they will reverse it.  I often wonder if they don't deny many just to see if we will appeal.  Think how many people don't have resources or know how to fight for themselves.  We are our own best allies.  Fight with them if you must!!!

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  • econmom
    econmom Member Posts: 73
    edited July 2008

    An update....

    Thank you all for your advice.  My doctor's assistant checked on it with the MRI place.  It appears that what was denied is the computer-aided-detection portion of the MRI, which most insurers do not consider separate, and the MRI place just writes it off.  Hopefully it is all cleared up.

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  • coonie
    coonie Member Posts: 7,618
    edited July 2008
    I agree with everyone about the appeal. My husband had to appeal dozens of claims. Can you believe one came back that they had denied for one of my chemo treatments, and it said "they didn't cover accidents !!!!
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  • Tirlie
    Tirlie Member Posts: 30
    edited July 2008

    Hi!

    I am MD, GP in Finland. In this country everybod gets the best treatment- and free! MRI is considered to be the best diagnostical means in bc. I have gone trough  all possible treatments mastectomy, chemo...PS  in August ( my friend from med school).

    I have read a lot of BC, and MRI seems to be the diagnostic measure of choice.

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  • jeffmen
    jeffmen Member Posts: 1
    edited July 2008
    One of the reasons that insurance companies may be denying an MRI as a source of "initial" diagnostic test is due to the cost.  My company sells ultrasound equipment and quite often, I have heard of insurance companies denying MRI's without the doctor conducting an ultrasound first.  Diagnostic ultrasound provides a very high quality image and can detect tumors quite well.  The results are instantaneous and the cost is significantly less.  Any sign of abnormality shown in the ultrasound should immediately be followed up with an MRI exam for confirmation.  Hope this helps.
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  • Analemma
    Analemma Member Posts: 1,622
    edited July 2008

    Unless you signed something explicitly saying that you would be responsible for any charges not paid for by insurance, the hospital has the responsibility to get pre-authorization for any procedures.  If they didn't get pre-authorization, they have to write it off.  On the other hand, if they pre-authorized it, they can't then deny it.  There's something else here, and it may be something as simple as incorrect coding.  It's a pain in the neck, though.  I just got off the phone from Aetna, trying to get a payment resolved from charges in January.  Every month when I get my hospital bill, I call Aetna.  Every month I think it's resolved, then, next month, it's still there.  Good luck!

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