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MRI denied by insurance

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Posted 7/26/2019 9:11 PM (GMT 0)
Hi all,
Pretty bummed to hear today that my request for a 3T MRI has been denied by insurance. My Uro and I have filed an appeal but the likelihood of success is not high. The price tag, out of pocket is $3500.... I'm not ruling out ponying up but its unlikely. That's a lot of scratch that could go towards my kid's activities and their needs. Any advice from the FBs? Let me know if there's an avenue worth exploring or if i'm just SOL.
Best to you all, BD
Posted 7/26/2019 9:45 PM (GMT 0)
Is your uro the guy you would have operate on you if you went with surgery?

Does he suggest an MRI for you or are you wanting it for yourself (more than he cares whether you have one or not?)?


The reason I ask....is.....there are surgeons who use MRI's as a matter of course in the treatment of their patients before they operate on them. If your uro isn't one of those, I'd find one. I'd make an appointment. And I'd tell him at the appointment that you want surgery. Once you get the MRI that he will want, you can then decide which direction to go with your treatment.

In other words, if your uro doesn't really believe you need on all that badly.....I'd find a doctor who does. Let them and let them do what they do best....getting honnery insurance payments. I think some know how to do it better than others.

That's just one suggestion. That's all.
Posted 7/26/2019 9:45 PM (GMT 0)
I dunno, but I suspect the denial was because you just had a biopsy less than 2 months ago which found low risk PC. Must docs would now recommend a conformational re-biopsy within 12-18 months. mp-MPIs are increasingly used now at the time of possible re-biopsy, as a less invasive and safer alternative to the biopsy. I’d suggest re-requesting in about 10 months...and be sure that the authorization request is for a “Np-MRI.”
Posted 7/27/2019 2:11 PM (GMT 0)
BD - Did they provide a reason for rejecting the MRI? The doctor may be more willing to push if he knows the reasoning behind the rejection. If it is for AS reasons then Blackjack is probably correct that it is just a timing issue (get the MRI before the next biopsy). However, if they have made up some stupid rejection reason (some reject claims as a reflex action) then you might have an easier time with the doctor. There usually is a formal appeals process as well that can be pursued.
Posted 7/27/2019 3:46 PM (GMT 0)
Hi all,
After reflecting on my interaction with my Uro re: the denied MRI, your replies are pretty spot on (not surprised).

Island Time,
The MRI was requested to pursue the wisdom of some length of AS for me (in conjunction with a genomic bio marker test and my bx results). Had i known the game a bit better, i might have stated my intention for immediate surgery, gotten an MRI, and crossed bridges after that.... I wasn't aware but i don't think that move is unavailable at this point so i may try this if my appeal is denied. Thanks for chiming in, i appreciate your take on this.

Blackjack,
You too are spot on. My Uro's office claimed that we'd have a much better chance getting an MRI request approved during the 12 mo. re-biopsy period. If i'm unable to get an MRI before then, i'll certainly try to play that card when i am retested. Thanks to you.

Mumbo,
Yes. The reason given: Not Gleason 7 or higher and with a PSA under 10. I'll let you all know how my appeals process turns out. Thanks for your reply.

Best to you all, BD
Posted 7/27/2019 4:39 PM (GMT 0)
Mine was denied as well, but I paid anyways. I should have done more research because here in Chicago there are third party establishments that do MRI's at half the cost,.
Posted 7/27/2019 6:50 PM (GMT 0)
When you look at what Medicare reimburses for scans (25% of billing), it would seem that private places like CDI (Epic Imaging in OR) would make a cash deal if insurance was not applicable. I think Idog is right at 50% and probably worth the trouble to call around if insurance remains an obstacle.

The stated criteria seems a little odd but maybe applies after a biopsy and you have a decent answer.
Posted 7/27/2019 10:16 PM (GMT 0)
I would check around for other sources of MRI. I know here (New Orleans) the hospitals charge considerably more for MRI (and MpMRI) then a local Diagnostic Imagining company.
Posted 7/27/2019 11:19 PM (GMT 0)
Great advice re: non-hospital MRI providers. I'll do some googling and call around a bit this week and let you all know what I find. Thanks.
Posted 7/28/2019 1:31 AM (GMT 0)
I don’t understand...what’s your rush to do this tomorrow?

You think the insurance company doctors don’t know what they are talking about, or that they have some conspiracy against you? They don’t. Chill. They’ll approve it in a couple months. You’ve got normal aging going on in the mean time.
Posted 7/28/2019 3:03 AM (GMT 0)
Whah?
BJ, where in any of my posts do i give you the impression that i'm in a rush or concerned about a conspiracy? Btw, just because i'm paranoid doesn't mean they're not out to get me.
Good day, sir.
BD
Posted 7/28/2019 11:28 AM (GMT 0)
Always start by understanding for what and when a procedure is eligible for reimbursement. Simply read your insurance agreement. If you find the denial is not in line with the agreement then the situation will be remedied easily. The language will include terms like “medically necessary” and “usual and customary”. In your low risk case, the MRI is not medically necessary and according to several posters it may not be usual and customary at the present time. Procedures that are nice to have but not really needed usually should be paid for by the patient. If you don’t want to cut the check then understand your insurance and use it in the way most beneficial to you.

My advice is to use your time to consider the various treatments available to you. AS, surgery, and several different forms radiotherapy are available and should each be assessed by board certified practitioners in each area so that when you treat you will have made a well thought out decision and there should then be no surprises or post-treatment regrets. Find and meet with the best AS program in your area. Find and meet with the best high volume prostate surgeon. Find and meet with the radiation oncologists that perform SBRT, permanent seeds and High Dose Brachytherapy. Your insurance will normally cover such assessments.

In your low risk situation, if you go past AS, then surgery, SBRT and the different forms of brachytherapy are equal in cancer control effectiveness, but will present very different situations regarding expected treatment side effects and treatment recovery. All this should be objectively assessed before taking action.
Posted 7/28/2019 6:21 PM (GMT 0)
Your Uro might still be in the lead here but I would bring a MO into the picture and maybe an RO too to get the big picture...Exactly what information do you hope to gain by having a 3T-MRI that you don't already know or that could be obtained by other methods..?
Posted 7/28/2019 8:35 PM (GMT 0)
(rule 3 - text deleted) This guy (the OP) has absolutely NO reason for an MO...not even close.x

Post Edited By Moderator (142) : 7/29/2019 7:19:37 PM (GMT-6)

Posted 7/28/2019 9:29 PM (GMT 0)
A lot of responses, but I would like to know your, and your doctor's reason(s) for getting an MRI. Are you trying to decide between AS and treatment (surgery or radiation)?
Posted 7/28/2019 10:51 PM (GMT 0)
Sr Sailor,
Yes, i'm trying to determine if AS, for any length of time, is possible for me.

In the meantime, i had a surgery consult 10 days ago and have a RO consult in August.
I've had my bx slides read 3 times and will be ordering a genomics test to be sent out this coming week.
My Uro seems to feel AS with a one year rebiopsy and 3 mo. PSA checkups will suffice, IF my biomarker test and this MRI came back favorable..... Praying.....
I'm really new to all of this and just trying to make good decisions and be thorough. It's really hard. Sorry if my posts have been confusing.

Best to you all, BD
Posted 7/29/2019 12:09 AM (GMT 0)
Beaverduck

I had a similar experience. However, after I cooled down, the denial made sense to me.

I already had a postive biopsy, and my URO wanted to do a second MRI guided biopsy. Insurance said no. The basic reason was that since I already had a biopsy showing cancer, this was just a drastically more expensive second biopsy. They explained that if my PSA was rising for unknown causes, and a standard biopsy found nothing, the MRI guided biopsy would have been an option they would have approved. I got a second biopsy, with very similar results as the first one, and proceeded to treatment (SBRT).

Good luck.
Posted 7/29/2019 1:52 AM (GMT 0)
So Beaverduck, are you in Oregon?
Posted 7/29/2019 4:06 PM (GMT 0)
JNF,
Yes. Grew up in Eugene, moved away for 20 yrs and back now but in PDX.

Island Time,
Good advice. I think i'm picking up what you're putting down.
I'll let you all know how things proceed.

Thanks again for replying to my post, BD
Posted 7/29/2019 4:55 PM (GMT 0)
My son lives in Springfield and we will be visiting later this month. We always enjoy the area.
Posted 8/1/2019 12:54 AM (GMT 0)

beaverduck said...
Sr Sailor,
Yes, i'm trying to determine if AS, for any length of time, is possible for me.

In the meantime, i had a surgery consult 10 days ago and have a RO consult in August.
I've had my bx slides read 3 times and will be ordering a genomics test to be sent out this coming week.
My Uro seems to feel AS with a one year rebiopsy and 3 mo. PSA checkups will suffice, IF my biomarker test and this MRI came back favorable..... Praying.....
I'm really new to all of this and just trying to make good decisions and be thorough. It's really hard. Sorry if my posts have been confusing.

Best to you all, BD


First of all, you are likely to make a good decision because you are considering various options and learning as you go along.
Now, with respect to the MRI and considering your biopsy results, it is my opinion that an MRI is not needed RIGHT NOW. You haven't clearly stated why you want an MRI, but I imagine it is to see if there are other areas of the prostate that need to be biopsied and whether any of the cancerous spots are close to the edge. True or not?
Posted 8/1/2019 1:38 AM (GMT 0)
Sr Sailor,
Thanks for the encouraging words. I hope all the studying i'm doing translates into good decision making when the real tests come... i'm not as optimistic as you but i'm doing my best.

Yes, my desire to have an MRI is to understand as much as possible about my case, in order to make the best decision re: AS. I guess i've been under the impression that after a positive bx, a genomic test and MRI can tell the most of the rest of the story and what path forward is best.

After doing more research and reading replies to this post here, i can see how a MRI isn't as crucial NOW as it may be prior to a one year re-biopsy.....

Thanks again for replying, BD
Posted 8/27/2019 4:41 AM (GMT 0)
Hi all,

Just an update.....
I received my Oncotype DX test results today and my score came back at 8. According to my URO and the website that is considered very low risk. I'm happy, i suppose. Considering my health luck lately, i'm kind of surprised for a favorable reading of any kind, from anywhere.... Additionally, i have a consult with a highly respected RO tomorrow.
The beat goes on..... Best to you all, BD
Posted 8/28/2019 2:11 AM (GMT 0)
Hi
Just an amateurs opinion
MRI very important if seriously considering AS
You need t know if there is anything more serious that biops,y missed
PSA a suggest no
More I potent than genomic test caus,e this, only reports what is found
If doing treatment then less important unless d.ocs need more info for treatment

Take care
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