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Diagnostic Mammos not covered by Aetna

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Posted 8/21/2012 9:11 PM (GMT 0)

I am a Breast Cancer Survivor!!

In 2007, I had a lumpectomy and then a mastectomy of my right breast.  Diagnosed with DCIS, non-invasive.

Since that time I go to NYU hopsital in New York for my mammograms.

Since changing my health insurance to Aetna NJ Individual Choice, I have had to speak to so many people, even in Texas, India and the Phillipines.

My physician requested me to have a diagnostic mammo and the insurance company will not put it towards my deductible.  The hospital charged $1031.00 for 2 or 3 photos, they were paid $733.00 and they are asking me for $831.00.  I also was charged for the radiologist to read it.  

 None of this makes any sense.  I only have one breast.

I have called Aetna and have been told that the routine screening mammos are covered and applied to deductible but diagnositic mammos are not.

Why should I be punished because I have had Breast Cancer?  I need this procedure as per my doctor.  She has given me a letter stating that this a medical necessity.

I live in the state of New Jersey and would appreciate any help with this matter.

Posted 8/23/2012 10:48 PM (GMT 0)
I used to have Aetna. Ugh.

Call them again tell them that paying for this now could save them a LOT of money in the future if your cancer has returned.

Best wishes!
Posted 8/23/2012 11:24 PM (GMT 0)
Thanks, I will try to convince them.

 

Posted 8/26/2012 7:38 PM (GMT 0)
Are they allowing the charge against your annual out of pocket? I'm with a different company, but have a lot of "no generic" meds. For those, they do not allow them against deductible, but they do consider them against annual out of pocket. It was very confusing, and took a while before anyone could explain the process.

Also, I have become very aggressive about pre-certifying even the smallest tests, even shots and meds.

Sad thing is that Aetna was so much better coverage.

An appeal sounds to be in order, and a call to your state insurance commission.

Posted 8/30/2012 10:17 AM (GMT 0)
I would change Insurance and quick, if you can't call your Doctors office and ask to speak to the person who handles insurance claims. If they have one who's trained they will know every piece of paper and every loophole needed to get your Insurance company to shut up and pay out. Good Luck mad
Posted 9/2/2012 12:35 AM (GMT 0)
The Blues in Pennsylvania are following a lot of other companies in having their approvals first OK'd by their own people, then turning it over to a hired company for a "real" approval or refusal. The hired company gets paid by the amount they "save" the insurance company, so guess what happens to a lot of requests? By the time the real approval or refusal comes in, maybe 2 weeks later, the tests have been run and the patient may be in for an unpleasant surprise.

You can't make much of an impact complaining to your insurance. I've tried. Your doctor can appeal the decision for you though.

One thing you can try if insurance doesn't cover something is to talk to the billing department and ask if they will accept as payment what the insurance would have covered if you pay it right away. They like it lots better than taking $20 a month or so. This often comes out to 60% savings. Borrow the money somewhere and pay the bill off if you can get this kind of deal.

We need to complain to our legislators to stop this insurance company practice. It's interfering with our doctors' practice of medicine and our health.
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