Insurance company denying test

[happyscooter]

My insurance company is denying a test that I need to have. I have already paid for one of these tests 2 years ago. $800.00. I don't think I should have to pay and I refuse to pay. So I am not having the test. Since I had this done before, I think this might turn out to be the same results. Not sure though. But I can't imagine a woman who has never had this done, gets a call from her doctor that she needs this, insurance company says 'no', and now every time she gets a spasm or twinge or whatever, she automatically thinks something is growing bigger inside of her. What was the point of me having the first test if they are going to refuse to do anything after that?

[Deleted]

Every insurance company has an appeal process- have you tried that? Is it a test that other companies routinely cover but your plan doesn't? How often is this test recommended after you've had one with a negative result? Is there a particular reason your doc recommends this test such as family history or symptoms that might indicate problems? Thise can be good ammunition for an appeal.

I thought that Obamacare required all preventative care to be covered 100% starting this year. I suppose there have to be limits to keep unethical docs from over-prescribing tests, but I'm not sure what they are.

[happyscooter]

Baseline mammogram came back with abnormalities. So they want to do a digital ultrasound. $800. I went through this 2 years ago, they denied it. I wrote a letter, my doctor wrote a letter and I contacted the insurance commission in NC. They still denied it. I had to pay out of pocket.

[zibazinski]

Get another mammo. A regular one. My place seems to now find "abnormalities" every year and since my insurance only pays for ONE screening, the next one is out of pocket. Of course, the second one is always fine but I am now starting to wonder and the next time I get my yearly mammo, I am insisting that there be a VERY thorough screening not perfunctory like I feel it has been.

[Deleted]

Yeah, I had one mammo where I got "the call" a day later. Something funny-looking, needed to do another. I went back and they used the same equipment but I think they just squished a little harder. It was normal and I've had another normal one since. I'm fortunate- my insurer paid for both, and the place I use does only digital. I was able to get through the worrisome weekend between the phone call and the repeat mammogram by reminding myself how hazy-looking they are. I have no idea how anyone finds anything significant on the film and it's probably easy to find something that might be an abnormality, but isn't.

One caveat I heard from a breast cancer survivor: get the actual report. What she found after her cancer diagnosis was that all along the report had said, "appears normal but her breast tissue is really dense so we're not sure". There's additional testing that can be done if you have dense breast tissue, but not if you don't have that information.

[Malarky]

I believe that insurance companies only pay for ultrasounds/ MRIs if you are in a high risk category. I had a mammogram every 6 months for 3 years followed by an MRI, because I am at high risk.
While I am pleased that it was covered, I would certainly have gladly paid out of pocket for the peace of mind.
I'm currently back on a yearly schedule, but that would change if anything new turned up. And I would pay for it if necessary.

[The Walk of the Penguin Mich]

What would be the alternative to the digital ultrasound? I'd probably ask to have it followed up via that manner.

I've had a couple of funky mammograms too. Each time, it's been followed up with an ultrasound and a needle biopsy. Kind of a pain in the butt, but rather safe than sorry.

When I was planning my last hip replacement, I wanted to go to the surgeon that my insurance company sent me to for the other hip. They approved, then a week before the scheduled surgery, denied the surgery (after everything had been set up and was in motion).

I also filed an appeal. My appeal was based around the fact that my insurance company had sent me to this surgeon in the first place and I was already under his care for one hip. It made absolutely NO sense to be under the care of 2 different surgeons, at 2 different facilities, in 2 different states!

Surgery went on as planned, I won my appeal.

[Deleted]

Jan 16, 2011 7:14:19 GMT -5 happyscooter said:

My insurance company is denying a test that I need to have. I have already paid for one of these tests 2 years ago. $800.00. I don't think I should have to pay and I refuse to pay. So I am not having the test. Since I had this done before, I think this might turn out to be the same results. Not sure though. But I can't imagine a woman who has never had this done, gets a call from her doctor that she needs this, insurance company says 'no', and now every time she gets a spasm or twinge or whatever, she automatically thinks something is growing bigger inside of her. What was the point of me having the first test if they are going to refuse to do anything after that?

What is the reason for the denial?

[happyscooter]

Not a standard test. I had the mammogram in Dec 2010. When they called me back for the extra testing, it was going to be in January 2011. So I called the ins. co. They said new year and I had to start over. But I couldn't have a regular mammogram because my year wasn't up. So DH called and asked, "If wife has a new mammogram in Jan. 2012 a year will have passed, so can she then have the digital ultrasound? It will be in the same year." The answer 'no, we don't pay for that'. My point is what is the purpose of having a screening mammogram if they aren't going to pay if anything shows up. I didn't even ask would they pay for treatments if I had cancer.

[❤ mollymouser ❤]

Have you asked your doctor is some other test might reveal anything useful ... since your insurer won't pay for the test that's been ordered?

[happyscooter]

No, I was too angry at the time. 2 years ago I paid because I had already had the test done. When I went in for my screening mammogram, the technician said 'any problems?' and I said 'I think a lump that I previously had is back.' I had it drained a few years earlier. She wouldn't do the test, sent me straight to the Dr. who sent me straight to the radiologist. Ins. Co. said I should have had my screening first so they wouldn't pay. Never mind I would have lost 2 weeks if there had been a problem.

Same company.

[happyscooter]

I will call the doctor tomorrow. Thanks for all of your responses.

[TheOtherMe]

Jan 16, 2011 10:33:31 GMT -5 @athena53 said:

Yeah, I had one mammo where I got "the call" a day later. Something funny-looking, needed to do another. I went back and they used the same equipment but I think they just squished a little harder. It was normal and I've had another normal one since. I'm fortunate- my insurer paid for both, and the place I use does only digital. I was able to get through the worrisome weekend between the phone call and the repeat mammogram by reminding myself how hazy-looking they are. I have no idea how anyone finds anything significant on the film and it's probably easy to find something that might be an abnormality, but isn't.

I had this happen to me the last week of December. I had to wait until January 3 for the follow up mammogram. Thankfully, I received a call the next day that all was fine. Even more thankful that insurance paid 100% of both tests.

[bean29]

Good for those of you who think to check with the insurance before you arrive for your appt. I of course only thought about it right before I went in for my Annual Mamogram. I had had a 6 month follow up slightly less than 6 months before on one side. They said not to worry, the radiologist had said "Return in Dec for Annual" so it would be covered. Unsure what to do but already there I went ahead with the test.

I just checked and they have paid for both the Mamogram and the ultrasound on the right side that was ordered for the 2nd time last year. They said all clear so I don't have to return until next year.

I would appeal and see what they say. Are your finances so tight that you just can't afford the test if the insurance will not pay? I don't think I could relax/sleep if I had something like this hanging over my head. I would pay OOP if I had to.

Good Luck.

[happyscooter]

Bean, the only reason I thought to check is because the last time they didn't pay, I was turned over to a collection agency, had to call the radiologist and set up a payment plan, write a letter to the ins co, have my doctor write a letter to the ins co, contact the ins commission of my state and still had to pay.

I just called my ins co with a diagnostic code. Still won't pay. She asked if the doctor was advising me to have the test since they found something wrong.

[happyscooter]

Do normal people just have extensive tests done to pass the time of day???

[happyscooter]

Paper we received in the mail last week states they now pay for speech therapy for autism, asthma tests, genetic testing for blood clotting, heart tests, smoking vaccine and 'Esteem Hearing Prosthesis for patients with sensorineural hearing loss'. Is that a hearing aid for people who don't want people to know that they wear hearing aids?

[Gardening Grandma]

happyscooter,
What about asking your dr to talk to the ins co? Or better yet, write them? We've had that work for us in the past.

[pepper112765]

Amazing. My annual mammograms include ultrasound, because I have had problems before. Three breast surgeries...luckily all benign. The OP definitely needs to appeal the decision.

[whoami]

I've had multiple mammagrams, ultasounds, surgeries etc since I was 28 and Im now 43. Nothing ever of substance really but its an ongoing thing. I am on the 6 mth sched at the moment with my next mammo and ultasound in April. I've never had any aggravation from my insurance company paying any of them. In fact, I dont even pay a copay for anything at the radiology place.

[pushingit]

Well this tells me that you don't really need the test so why should insurance pay? I mean, you're willing to forgo it if you have to pay yourself, so really . . . do you need it or not?

[shanendoah]

happyscooter: As I have mentioned in another current thread, I work for an insurance company, and up until 6 months ago, I worked in the department that handled authorization (pre and post) as well as appeals. So here are my questions for you:
Is your insurance an HMO/MCO that requires pre-authorization? or are you just checking in advance because you had to pay out of pocket last time?
Has your MD offered any alternative diagnostic options to the digital mammogram?
Can you go to your insurance company's web site and search for their clinical criteria? Many post them on the web. If they aren't posted on the web, call customer service and request a copy of the clinical criteria they use in determining whether or not to cover digital mammography. (I will note that my company doesn't believe there is a whole lot of evidence as to the efficacy of digital mammography, but covers it without review regardless, because it is becoming a standard of care in the community.)

What having the clinical criteria in hand does is tell you if you meet the conditions required for your insurance company to pay for the test, if they cover it at all. If you don't meet the clinical conditions, or they don't cover it, there's nothing you can do to get them to pay for it. At that point, you need to discuss with your doctor the best plan for you going forward both medically and financially.

If your insurance company covers digital mammography and you meet the clinical criteria (if there are any), then have the test done. Considering that your regular mammogram was in December, and this is a follow up and should be covered regardless of calendar year.
If your insurance company then denies you, appeal. If they deny your appeal, DON'T SETTLE THERE! Your mistake last time was that you wrote a letter to the OIC, but you didn't follow up with any action. State regulators understand that your first level of appeal is to the insurance company, and its in their financial best interest to deny you. You ALWAYS have at least 2 levels of appeal available to you (sometimes 3).
So, if your first appeal is denied, say you want to challenge the appeal. At that point, the insurance company will have to send it to an IRO (idependent review organization), the OIC, or an ALJ (administrative law judge). Where it goes depends on the contract you have (your employer has) with the insurance company. These are outside agencies that will review the medical record, the contract, and also make a determination based on the reasonable person standard. You are NOT responsible for any expenses accrued in getting the appeal.

[jkapp]

Jan 18, 2011 9:16:27 GMT -5 happyscooter said:

Paper we received in the mail last week states they now pay for speech therapy for autism, asthma tests, genetic testing for blood clotting, heart tests, smoking vaccine and 'Esteem Hearing Prosthesis for patients with sensorineural hearing loss'. Is that a hearing aid for people who don't want people to know that they wear hearing aids?

Well, see that's why they won't pay for another test for you - they have five additional procedures to pay for other people...