Insurance refusing to pay for 'medically unnecessary' MRI??

[Anonymous]

Long story short - doc ordered MRI to check for a possible relapse of a sports injury that I'd had surgery to correct a few years ago. Went to get the MRI and paid a co-pay of $400 at the appointment. Now, I just received a bill from my insurance for $1000 because they are denying coverage due to the MRI being "medically unnecessary". This seems absurd and unreasonable to me but I don't even know where to begin!? Anyone have any experience with something like this? How do I go about appealing this decision?

[Anonymous]

Call your doctor and ask them to follow up with your insurance directly to explain why the MRI was medically necessary. If you don't have the doctor's support, you can file an appeal through whatever process your insurance company has (up to two appeals). Good luck. I had to appeal twice to get my newborn's mandatory hearing test covered by insurance. Health insurance in this country is an abomination.

[Anonymous]

MRIs are expensive. Typically, you have to get insurance pre-approval before getting one if you expect your insurance to pay. That usually doesn't apply if it's done as part of an ER visit.

[Anonymous]

This is a common problem where a doctor orders tests/MRI, etc... and has no idea if the patients insurance will cover it. In all fairness there’s no way a doctor can keep track of what medical tests/procedures will be covered simply because there’s just to many plans and limits to keep track of. On ANY non emergency test/procedure it’s the patients responsibility to make sure it’s covered or has a referral for it prior.

On the positive side, I had an MRI last week and the cost was $4,000. Consider yourself lucky. Hopefully if you resubmit the bill with a doctors letter it’ll be approved. All insurance companies have a process to deal with this.

[Anonymous]

Depends on the insurance, but I was able to request a review of the claim and included a letter explaining why the procedure was necessary. That got denied again and then I went to the formal appeal process (2 rounds). Call your insurance company and they can tell you their process. (And get the doctor to write a letter of medical necessity.)

[Anonymous]

Thanks all - this is really helpful advice on where to start.

[Anonymous]

Call the doc office and ask them to re-code the MRI for something the insurance will cover. There are various medical codes and some are more fickle and will get denied while similar codes, only slightly different, pass.

[Anonymous]

Moral of the story: avoid over-consumption of health care costs. Doctors order x-rays and MRIs all the time just because they'd like to know more, not because the information is actually necessary for your treatment. Checking for a "possible relapse of an old sports injury" does not sound medically necessary.

[Anonymous]

Anonymous wrote:This is a common problem where a doctor orders tests/MRI, etc... and has no idea if the patients insurance will cover it. In all fairness there’s no way a doctor can keep track of what medical tests/procedures will be covered simply because there’s just to many plans and limits to keep track of. On ANY non emergency test/procedure it’s the patients responsibility to make sure it’s covered or has a referral for it prior.

On the positive side, I had an MRI last week and the cost was $4,000. Consider yourself lucky. Hopefully if you resubmit the bill with a doctors letter it’ll be approved. All insurance companies have a process to deal with this.

Doctors SHOULD be cost and resource conscious. They should not order invasive/expensive tests unless they know they are really necessary.

[Anonymous]

Anonymous wrote:Moral of the story: avoid over-consumption of health care costs. Doctors order x-rays and MRIs all the time just because they'd like to know more, not because the information is actually necessary for your treatment. Checking for a "possible relapse of an old sports injury" does not sound medically necessary.

+1000

[Anonymous]

Was the MRI done at the doctor's office? My orthopedist has an onsite MRI. They are basically self referring and giving themselves a kickback when they order an expensive test. It's really hard for insurance companies to rein in some of this behavior. It's up to the patient-caveat emptor.

[Anonymous]

Yeah I had to have six weeks of pyshical therapy for a recurrence of a neck issue before insurance approved an MRI. It can be a dance...especially with things they see as not life threatening

[Anonymous]

Did the dr contact your insurance for preapproval?

[Anonymous]

Anonymous wrote:Did the dr contact your insurance for preapproval?

Obviously not or she won’t be here asking!

[Anonymous]

I wasn’t even able to get an MRI until my insurance approved it. The provider wouldn’t do it.