Author Topic: 1 year Follow Up MRI denied by Blue Cross  (Read 4507 times)

mac84

  • Full Member
  • ***
  • Posts: 114
1 year Follow Up MRI denied by Blue Cross
« on: April 17, 2016, 03:54:47 pm »
Got a letter on Saturday denying approval for my MRI at Vandy on Monday. Extremely bad timing since I've got to drive 4 hrs to this 1:45pm appointment on Monday.

As near as I can figure, it looks like BCBS changed their criteria on 6/13/15 and also sub these reviews out to a third party.

Here's a link to the new criteria. Going to have to make the drive and fight this on the way since I also have a hearing test and Dr. visit on Tuesday

https://www.carecorenational.com/content/pdf/DD/D4AB1AFF55634CAAA8BBCF83FE9A325A.pdf??body=
Diagnosed 10/13/14 with 1.4cm AN L side
1st Consult with Vanderbilt 11//14
W/W.  Next MRI in April 2015 at Vanderbilt.
April 2015 MRI no growth -
April 2016 MRI no growth - still 1.46cm.
4/17: No growth!
4/18: No growth! MRI 2 yrs
4/20: No growth! Symptoms stable- MRI 2 yrs

alabamajane

  • Hero Member
  • *****
  • Posts: 610
Re: 1 year Follow Up MRI denied by Blue Cross
« Reply #1 on: April 17, 2016, 04:37:09 pm »
Sorry to hear that mac84,,,, no one likes glitches when dealing with an already stressful situation!
Did they give a reason??
I sure hope you get some resolution soon!

Jane
translab Oct 27, 2011
facial nerve graft Oct 31,2011, eyelid weight removed Oct 2013, eye closes well

BAHA surgery Oct. 2014, activated Dec. 26

mcrue

  • Sr. Member
  • ****
  • Posts: 357
  • Greg Mech
    • gregmech26
Re: 1 year Follow Up MRI denied by Blue Cross
« Reply #2 on: April 18, 2016, 02:43:30 am »
I certainly feel for you Mac84.

Just 3 days before my family and I were supposed to make the long drive from Michigan to Pennsylvania to have my Gamma Knife brain surgery with Dr. Lundsford, his hospital (UPMC) called very late in the afternoon to deny my treatment even though my insurance BCBS had me pre-approved with a written letter. Dr. Lundford's personal nurse even sent me an unsolicited email saying I was "all good to go" on the insurance front. To this date, no one has ever apologized from Dr. Lunsford's office for all the anxiety, waste of time, and replanning they caused. It still leaves a bad taste in my mouth.

Anyhow, as you know, MRIs are very expensive. I hope you can work it out in your favor with BCBS, as obviously most everyone with an Acoustic Neuroma will need a one-year follow-up MRI regardless if they have had treatment.

Best wishes.
5/19/2015 - 40% sudden hearing loss + tinnitus right ear

6/26/2015 - AN diagnosed by MRI - 14mm x 7mm + 3mm extension

8/26/2015 - WIDEX "ZEN" hearing aid for my catastrophic tinnitus

12/15/2015: 18mm x 9mm + 9mm extension (5mm AGGRESSIVE GROWTH in 5 months)

3/03/2016:   Gamma Knife - Dr. Sheehan

mac84

  • Full Member
  • ***
  • Posts: 114
Re: 1 year Follow Up MRI denied by Blue Cross
« Reply #3 on: April 20, 2016, 12:54:56 pm »
Ok, an update. I drove 4.5 hrs to my MRI appointment and called several times on the way up to Nashville. Once I got through to the 'third party' that made the decision to deny the MRI I was told that it had been approved. 

The real story here is that Dr. Rivas called their 'medical director' and talked with him about the whole W/W protocol. He indicated that he had to educate him about needing regular MRI's to monitor growth and that what we were doing was a conservative thing.

Dr. Rivas indicated that he's had to this a great deal lately and that he'd do it each time if he needed to. Once educated about it the medical director agreed with it and seemed to 'find it in the fine print'.  ::) ::)
Diagnosed 10/13/14 with 1.4cm AN L side
1st Consult with Vanderbilt 11//14
W/W.  Next MRI in April 2015 at Vanderbilt.
April 2015 MRI no growth -
April 2016 MRI no growth - still 1.46cm.
4/17: No growth!
4/18: No growth! MRI 2 yrs
4/20: No growth! Symptoms stable- MRI 2 yrs

alabamajane

  • Hero Member
  • *****
  • Posts: 610
Re: 1 year Follow Up MRI denied by Blue Cross
« Reply #4 on: April 20, 2016, 06:33:27 pm »
Thanks for update and glad you were successful in getting it worked out

Good luck with the results also.
translab Oct 27, 2011
facial nerve graft Oct 31,2011, eyelid weight removed Oct 2013, eye closes well

BAHA surgery Oct. 2014, activated Dec. 26

Sheryl

  • Sr. Member
  • ****
  • Posts: 456
Re: 1 year Follow Up MRI denied by Blue Cross
« Reply #5 on: April 21, 2016, 06:48:21 pm »
So glad it worked out.  Insurance companies drive me nutz!!  I used to work for a group of physicians and do their billing (many years ago) and I would fight for every penny.  Usually BC-BS is pretty good and if the doc gets involved, they will agree. 
Sheryl
9th cranial nerve schwannoma - like an acoustic neuroma on another nerve. Have recently been told it could be acoustic neuroma. Only 7 mm of growth in 18 years. With no symptoms. Continuing W&W

mac84

  • Full Member
  • ***
  • Posts: 114
Re: 1 year Follow Up MRI denied by Blue Cross
« Reply #6 on: April 22, 2016, 09:01:57 am »
Thanks all.....yes, glad it worked out.

No real changes...going back in one year. Glad to be on the W/W!

He did suggest a hearing aid for the tinnitus. I can't imagine that right now......
Diagnosed 10/13/14 with 1.4cm AN L side
1st Consult with Vanderbilt 11//14
W/W.  Next MRI in April 2015 at Vanderbilt.
April 2015 MRI no growth -
April 2016 MRI no growth - still 1.46cm.
4/17: No growth!
4/18: No growth! MRI 2 yrs
4/20: No growth! Symptoms stable- MRI 2 yrs