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Doc says my insurance is appealing my MRI...?? the heck?

Saw my new PM doc for the 2nd time today, first month I asked him to order an mri for my lower back, which he did. I've had two previous MRI's in 09 and 010 which show a herniated, degenerat(ing) L5-s1 disc.

I never got the call from the MRI place and Im not in a hurry to do it so I figured i'd wait for my next apointment and before I even mention it, doc says: So my recip just told me your insurance is appealing your MRI because there gettin expensive.

what the heck is that? can my insurance even do that? would they do that? or did the docs reciptionist just forget to fax it?

Im not so sure about this doc, at my first appointment he told me that he himself is getting a XLIF fusion done by our local ortho spine surgon in the next couple weeks. (the same surgon who ive seen and is considering a fusion for me) but it turns out the doc went on vacation during those two weeks, Doc lied to me for no reason? pfff... so he can say he did it and it went like a breeze, I was back to work in less than a week!, well he didnt say that last part but Im bettin he would.


  • No offense intended, but if someone says they have a fusion coming up, should you really criticize and call them a liar? I bet you get ticked off when people doubt your problems.

    Think about it.

  • your Doc out, you really don't know what he is dealing with.
    Yes insurance are being more picky, if the right diagnostic coding isn't privided they will deny coverage. I've had two blood clot tests taken before nerve blocks and the lab didn't use the right coding and the kept submitting it with the wrong code, got turned down so many times my insurance told them it was no longer appealable.
    laminectomy c4/c5 2008, ACDF c4-c7 Jan 20 2014 sched
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  • dilaurodilauro ConnecticutPosts: 11,630
    Insurance I was surprised when you say you TOLD your doctor to order a MRI! I haven't seen my patients telling the doctor what is needed. Many times that can back fire in your face. Insurance companies have guidelines to follow.
    First the doctor must put in the proper charge codes for the MRI and provide justification and rationalization for the need of a MRI. Insurance companies may refuse a MRI based on improper coding of the treatment and if there is no valid justification to justify putting out the money for a MRI.

    Doctor's Private life Heck, he/she can tell you they have a surgery coming in in 3 weeks, and for whatever reason, that doesn't happen, they dont owe you or anyone else with details. More than anything, surviving as a chronic pain patient, you need to have a strong ally in your doctor and have a solid two way relationship.
    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
  • Oh yeah, Insurance can and usually does deny MRis and the appeal process can be difficult. I work in a doctors office where we must order tests for patients and have to dot evey i and cross ever t and then sometimes they still deny them. I don't understand why if you have them in 09 and 10 why you feel the need to want another one. Have you had increase in pain or symptoms that would warrant another MRI. My provider who I also work for is really good about making sure the tests I need are ordered but you have to go through the hoops with insurance by starting with x-ray and if that shows changes along with new symptoms usually helps to get it approved. Even with all the problems seen on my x-ray and trying medications, PT.... the insurance fought but eventually approved the MRI. Then when MRI showed some pretty significant problems that needed surgery my NS needed me to have CT to see what type of surgery I would need. The insurance still denied the first time and did a peer to peer with my NS before they would approve. I have never seen an insurance company, and I deal with alot of them, just approve because a patient wanted one.

    I agree with Ron about having a strong, trusting relationship with you doctor. As long as your care is not suffering I would just let the issue with him "lying" to you go. I know in Western NC where I live we do not have much choice in PM providers and they will drop patients in a heartbeat for non compliance. Sad but the DEA is cracking down on them so therefore they have become very strict with patients. I wish you luck with your doctor and hope he can help you with pain relief.

  • My insurance uses a separate vendor to decide whether or not any major diagnostic testing( MRI, CT scans) will be done. The doctor's office will get it certified medically necessary then i will receive a letter stating whether it was approved a few days later.
    Discectomies 05/08 and 04/11, fusions L4-5 Feb 9,2012 and L3-L4 June 28,2012, Staph infection washout 3/2/2012, Bulged L5-S1. SCS trial on January 17th, 2014, which was a success! Permanent SCS on February 20th.
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