Does this seem right (health related)?

debo_2006

14 years ago

Long story short:

Had a mammography which showed something. Was told by the radiologist to get an ultrasound so they could be sure it was something. The ultra confirmed that something was there so they did a biopsy. Biopsy came back as pre-cancer (LCIS). Met with BC surgeon who said it should be removed and she also ordered an MRI to be sure there was no more of these cells showing up anywhere else that couldnÂt be seen on mamm or ultra. I also took a genetic test for BC. After results came in, met with surgeon again for results and surgery discussion. She told me MRI came back indicating the LCIS was only in the one original area and the genetic test was negative. My mom is a BC survivor so my chances are higher which is why she wanted to run all these tests. Surgeon had me schedule breast surgery for mid-May to remove the findings so they wonÂt have a chance to possibly develop into BC later.

I donÂt know how the docs office billed my BC/BS Traditional insurance, but I just received a letter from BC/BS saying they will not cover the MRI. I called the insurance company beforehand to insure it would be covered (I usually do that). IÂm pretty sure they told me it was covered which is why I moved forward. The letter says it was an investigative test (MRI). What????? BTW, this is an IN-NETWORK provider.

I would think since BC runs in the family making my chances of getting it higher, plus they found something (LCIS), that the insurance company would pay their portion of the MRI, and me my portion. I just didnÂt expect my portion to be 100%. TheyÂve always covered MRIÂs in the past for injury related things like knee, shoulder.

I intend to call the surgeonÂs office on Monday, then the insurance company for an explanation. This is going to be a huge bill and I will appeal it if I can.

Does this seem right or wrong that they wonÂt cover it?

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Comments (10)

mariend
14 years ago
I just read something that scares me and should scare all of you. Many insurance companies, including Blue Cross (Anthem) are increasing payments, canceling policies, denying procedures because of exactly this person is talking about. Because breast cancer appears to be in the family, they will continue to deny benefits. One way they are finding out the information, is they are "being" friendly, calling you saying they want to help you, asking about family history etc , and yes this has happened to me. Also all the information you have to give to the medical staff is given to your insurance company and remember your insurance company will do anything to keep from paying your bill. Read your policy, and check with your state insurance board to make sure they are not denying you coverage.
carla35
14 years ago
Are mammograms for your age group covered in your plan; how often? Although it may be beneficial for you personally doesn't mean it's covered.

Also, could it be that you haven't met your deductible yet this year? What is your deductible amount?

Another thing... possibly the doctor's office coded it wrong... maybe it was suppose to be coded as a yearly exam but got coded as an investigative exam instead, or something similar.

I don't know if it seems right that they would or wouldn't cover it because I don't know your plan or your conversation about preapproval... but I would guess that just because it's the smart idea for you personally to get a test or that there's a higher chance of you getting something, doesn't necesarily mean something will be covered.
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Vickey__MN
14 years ago
Appeal this. You can win appeals (someone on here just did..Heather in Ohio I think). Get your doctor's office to help with the appeal if you need to.

Vickey-MN
trinitytx
14 years ago
Gosh, if you think about it....aren't all MRI scans investigative tests?
Keep after them....they need to pay for this.

Trin
organic_donna
14 years ago
This is why we need Health Reform.
susanjf_gw
14 years ago
what happen to the hmo concept??? health MAINTANCE org...

we had reg bcbs, went to hmo bcbs and they're refused to pay for my kidney pills anymore...thanks be doc had an alternative, or what? then they'd have to care for more complications??? doesn't make sense, does it?

wonder what the cost will be for the mammo i have in may?

btw our local karmanos cancer is tesitng a new alternative to boob squish...you lay face down on a canvas table, with your boob suspended in a vat of water, and they do an ultrasound...amazing! supposed to "see more" and up to the breast wall of the chest (where my cancer was and i couldn't feel) best? NO pain!
debo_2006
Original Author
14 years ago
Trin - that's my point....all MRI's are investigative tests to *see* what they may find. I just don't see how this one is any different than other bodily MRIs that they paid for in the past.

Just doesn't make sense and I'm NOT letting this one slide by. In fact, I am postponing my breast surgery until this is cleared up b/c I don't need any more surprises by the insurance company. I've had great insurance through my DH's internationally known company for 30 years now, and this is the first time I've ever encountered an issue like this.
yayagal
14 years ago
I had a similar experience and I called the state insurance commission and they took care of it for me. You can definitely win this one. Before you do that call your insurance company and see if it was coded in right. Ask to speak to a supervisor. Good luck.
carol_in_california
14 years ago
My DD has no health insurance and got a mammogram through the EOC. If was abnormal so she needed a repeat mammogram on the left side along with ultrasound.
She asked the office secretary if she would get a discount since she was going to pay cash. She did get a discount and the left breast mammogram and ultrasound cost her $123.
I hope you can get your problem resolved easily.
Keep us updated, please.
Terri_PacNW
14 years ago
Do you have a written record of when you spoke with the insurance regarding the "pre check" on whether they would cover the MRI? Whom you spoke to and what day?

Also I would think that your doctors office that ordered it would have checked with the insurance as well. I'd put them on my calling list to ask questions of as well.

Does this seem right (health related)?

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mariend

carla35

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Does this seem right (health related)?

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