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My MRI was denied

AnonymousUserAAnonymousUser Posts: 49,578
edited 06/11/2012 - 7:28 AM in Health Insurance Issues
When i logged into my health insurance account, my MRI claim was stating that it was denied. The amount was for $1250. My doctor called and set the appointment up and told me where to go. I then called my H.I. and asked them if it was in my network and they said it was. I had a herniated disk that i tried PT for a couple of weeks but was only making it worse. Thats when i called the doc to see if we should set up the MRI and she agreed. After the MRI results where back she said i had to goto the Neuro. So i got setup with the Neuro which he said i could put a band-aid on it (the Injection), live with the pain, do a microdiscectomy, or do a spinal fusion. I choose the Micro.

Anyways, why would they deny this claim? do they have a legitamate reason to deny it? when i call to find out why, what do i need to ask them, besides the obvious? Anything i can say or do to make my case look stronger for me? I can already see it now that they are going to hassle me on the surgery which i called and told them i was doing and they said ok. grrrr


  • after looking at my denied claim which also includes a denied claim for an office visit for $170 as well, it said it is denied due to a pre-existing condition. WTF, why would they think that? I havent been to a doctor in 10 years and havent had back pain prior to this summer. I just started this healthcare provider on May 1st 2008 after i switched from another company when they jacked my rates up over 40%.

    i beleive that i herniated my disc this last summer and have managed the pain until i sneezed in January and sent that disc out further to the point where the pain was unbearable and couldnt walk. so i dont know how this would be a pre-existing condition. It said they would like to see my medical records...ok, where do i get those?
  • dilaurodilauro ConnecticutPosts: 11,348
    some type of diagnostic test or treatment is because the doctor has not provided enough rationale, or a 'business case' to indicate that the procedure is necessary. I have personally seen the same patient, with two different doctors. Same insurance company, one request was denied, the other accepted. It was not because of the subject (patient) it was instead how the doctor wrote it up.

    I have seen some of the documentation that doctors provide when they want to get a MRI approved for one of their patients. Strong words such as Must have, Critical, Not many other options need to be included.

    Some doctors get a bit leary of some patient situations. I have heard of a patient that was basically a hypochondriac and wanted to have a MRI done every month to see what damage has ben added Thats a bit extreme but try to put yourself in the insurance auditors position. What do you waht to hear and read that will make you an approvded candidate
    Ron DiLauro Veritas-Health Forums Manager
    I am not a medical professional. I comment on personal experiences
    You can email me at: rdilauro@veritashealth.com
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  • If I have a procedure or doctor's visit scheduled, I always have the doc's office contact my insurance company ahead of time to have the procedure approved. As far as my neck goes, the MRI was a last minute thing (the doc wanted it ASAP as soon as he saw the X-rays), but it was approved. As for surgery, university hospital that I had my ACDF had everything pre-approved before I checked in. I have an unrelated procedure scheduled for Feb 19th and the first thing I did when I scheduled it was have the doctor's office get the procedure approved. Just making sure they are "in-network" isn't always enough.

    I also learned that most insurance companies work off of codes....diagnostic and treatment codes...to determine if something is covered. My chiropractor was actually the one who explained this to me when I first injured my neck and he was very careful about using the codes he knew would "work". I would talk to your doc and let them know about the denied claim to see if they can submit it differently in order to get the claim approved.

    BTW, the doc that ordered the MRI and the facility that did it will have your medical records. All you have to do is sign a release and they will give them to you or even send them directly to your insurance company with your approval.
  • I talked to the insurance company and they just said i needed to provide proof of insurance coverage and all doctors ive seen. So i have them sending me that now and hopefully all will be taken care of.
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