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MRI - Insurance Denied Coverage

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Posted 4/9/2018 12:16 PM (GMT 0)
I have Aetna insurance and had a MRI schedule for six months . A day before the MRI I received notice that insurance would not cover the exam and they cancelled the MRI.

My prostate history is below.

I plan to appeal. I am writing here to inquire and determine if this is common or have I been singled out?. Also any ammunition you could provide to the appeal process would be appreciated.

Here is the statement from Aetna's reviewer:

Based on eviCore Oncology Imaging Guidelines, we are unable to approve the study your doctor requested. Your records show that you have or have had disease in your prostate in the past. Your prostate is a gland that surrounds the neck of your bladder. Routine follow up advanced imaging, detailed picture study, is not supported for disease involving the prostate. Advanced imaging is supported for disease involving your prostate if one of the following applies to you: 1) you have signs and/or symptoms that suggest your disease has progressed, or 2) you have results of blood and/or tissue sample lab tests that suggest your disease has returned. Your records do not show that one of these applies to you.

Thanks for your help....
Posted 4/9/2018 6:18 PM (GMT 0)
I thought from reading here on the forum that MRIs weren't a diagnostic for the presence of cancer?
Posted 4/10/2018 12:34 AM (GMT 0)
The finding that the PSA has gone down may have been the crucial factor in Aetna's decision.
Posted 4/10/2018 12:45 AM (GMT 0)

Sr Sailor said...
The finding that the PSA has gone down may have been the crucial factor in Aetna's decision.

Horizon BC/BS did not like that I was only G6 as well! The denied me numerous times but MSKCC got it done eventually! yeah Keep working it Aetna may cave if you keep the pressure on them! Squeaky wheel gets the grease! yeah
Posted 4/10/2018 12:52 AM (GMT 0)
Htownman:

I had an MRI / Fusion biopsy refused after my PSA went up. My UR and I haggled with UHC for several weeks. I eventually just got a TRUS biopsy. My scores went up, and now I am scheduled for SBRT in about 2 weeks.

It is my understanding that the MRI is easier to get approved if you have a rising PSA and no PCA in the biopsy. If other reasons for the rising PSA are ruled out, the MRI can help find something that the biopsy has missed. Since your PCA is confirmed and the PSA is going down, perhaps that is the reason.

Ironically, I chose SBRT for treatment, and UHC approved the MRI necessary for simulation planning without a hitch.
Posted 4/10/2018 2:27 AM (GMT 0)
Sorry to hear your insurance company will not pay for the MRI. So many problems with insurance companies it is just that. I would go thru the appeal. What does the DRE show - anything positive on the DRE would help I think. The PSA values will vary some and so get it repeated and also include the free PSA. You could also include some other possible tests indicators that indicate the Pca is more advanced than what the biopsy is showing. Good luck.
Posted 4/10/2018 12:27 PM (GMT 0)
Husband has bone mets and lymph node involvement. Even though there were known mets on his spine, the insurance (BS/BS) denied CT scans above his waist and of course the MRI was out the window! Our radiologist was furious, appealed twice and then fudged the scans as high as he could get away with it.

I love our radiologist!

I can sort of understand, but it does help the doctor's see what may be coming up the line if they can get an early picture of what is going on.

Husband has been having some pain around his sternum but the MO feels as if it's some inflammation and nothing to worry about. *fingers crossed*
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