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        New Message Board Archives >> 2003 Posts >> MRI/MRA Denied!
        
(Message started by: LasVegas on Dec 12^th, 2003, 1:53pm)

Title: MRI/MRA Denied!
Post by LasVegas on Dec 12^th, 2003, 1:53pm

I just received a letter in response to my appeal from the insurance company who declined my MRI and MRA ordered by the neurologist. This is their response....

"The clinical information submitted does not document any changes in your symptoms or condition to warrant an MRI/MRA of the head. Per Healthcare Operations protocol "Imaging is not generally indicated for patients with chronic headache without associated neurologic signs and symptoms; it is uncommon to discover any imaging abnormalities in this setting."

This is somewhat true based on what I read on this site regarding MRI/MRA findings. But that makes me wonder a few things....
1. How come MRI's and MRA's get ordered?
2. How do some of you who have had MRI's and MRA's get the insurance companies to accept paying for them?
3. Who the hell is the expert on CH's within Health Plam of Nevada, Inc., a subsidiary of Sierra Health Services, Inc.? Just curious who knows about CH's over there, because as far as I know, I still have been the primary educator to the medical professionals.

Very frustrated, but at least PF.
Gregg in Las Vegas

Title: Re: MRI/MRA Denied!
Post by Paigelle on Dec 12^th, 2003, 1:58pm

Gregg,

I use to work with billing insurance alot. What a pain in the ass! Anyway, first of all are you with a PPO or a HMO. Either way YOU can fight their decision some more. Have your Dr write a letter stating that with CH you also have drooping eyelid. This almost warrants a MRI because of concern that paralysis might be involved. Next, find out who your state insurance commissioner is, write him a letter and send a copy to your insurance company. If they are denying this, then they might start denying payments to your Doc.

Title: Re: MRI/MRA Denied!
Post by LasVegas on Dec 12^th, 2003, 2:05pm

HMO. Have only seen this "nurse practioner" at the neurologists office once. I've been PF for over 2 months and therefor don't know if visiting again for a $50 co-pay is going to be worth it. What do you think? Also, the findings that I read on this site and related links show no signs of anything at all when doing an MRI or MRA (especially our of cycle or not during an attack) except for an increased mass of grey matter. Please correct me if i'm mistaken. Any suggestions based on this?
Gregg in Las Vegas

Title: Re: MRI/MRA Denied!
Post by Cluster_head on Dec 12^th, 2003, 2:16pm

If you've been PF for two months, it sounds to me like your episode has ended. Episodic sufferer right? I'd blow-out the MRI unless you need peace of mind that your HA's aren't caused by something else.

Title: Re: MRI/MRA Denied!
Post by Paigelle on Dec 12^th, 2003, 2:32pm

You might have to have your PCP do the referral for the MRI. Usually a HMO will not pay for squat unless the referral comes directly from the PCP, even if the PCP referred you to the neuro. Also make sure that your neuro office isn't billing under the nurse practitioner. In some cases, an insurance company will only pay if the treatment is billed under the dr.

Most insurance companies before paying for a MRI want to know if the diagnosis could be life threatening. Little do they know that CH is life threatening, we are in such pain we want to kill ourselves. However, most insurances will pay, if the referring dr. will note the diagnosis as something dealing with the drooping eye. Since most CH patients have the droopy thing. If the dr. uses a diagnosis like that, then it is basically stating something neurological maybe going on and they are trying to rule out blood clot, aneurysm, or tumor. It might just be a simple as a diagnosis code change that needs to be done.

Title: Re: MRI/MRA Denied!
Post by Paigelle on Dec 12^th, 2003, 2:33pm

Also, (man this is really long) with a copayment that high, if you are out of cycle and do not need in immediate pain meds or anything, have the neuro reschedule the MRI for alot later. If you know for sure nothing life threatening is going on, then waiting for the MRI won't be so bad. And like you said our MRI's and CT scans don't ever show anything.

Title: Re: MRI/MRA Denied!
Post by LasVegas on Dec 12^th, 2003, 2:33pm

I agree to say forget about getting it done. Didn't think it was warranted to get an MRI or MRA to begin with based on studies I have researched. However, everybody seems to agree tat MRI ad MRA are normal procedures to get done. Who knows if it is something else? It does take research of many to come up with documentation right? What if it was a tumor or an anneurism or something else in the head? All of us are individuals with our own DNA, our own triggers, our own everything, but share some symptoms in common that call us "ClusterHeads." Also, if I give up the fight with the appeal process, where does this lead research study on CH's and validity of the need for medical professionals to acknwledge and place more effort into this disease? Not sure which direction to go with and would appreciate some replies, as I feel alone in this battle as if my Cluster Headaches are no big deal to the insurance company, the pharmacy, the neurologist and my primary care physician.
Gregg in Las Vegas

Title: Re: MRI/MRA Denied!
Post by Paigelle on Dec 12^th, 2003, 2:37pm

Unfortunately you are correct in wondering where do we go from here with insurance and drs. It is even hard for us, as sufferers, to educate the medical profession when they are not willing to listen. Many drs and nurses believe they know it all and we are just stupid when it comes to our own bodies. Little do these drs know that we have all spent countless hours researching this disease and searching for a remedy. The best thing that could be done is OUCH could offer seminars for educating the medical profession on this condition.

Title: Re: MRI/MRA Denied!
Post by phishphan on Dec 12^th, 2003, 2:59pm

thank god for canadian health care

Title: Re: MRI/MRA Denied!
Post by Melissa on Dec 12^th, 2003, 3:24pm

Gregg, were you diagnosed with CH's before or after your neuro ordered the MRI/MRA? I'm just curious.

In my case, the MRI I had was done before I was diagnosed, it helped to determine what was causing my HA's. Insurance companies are like that, unless there is a change in your condition, they see no reason to warrent one. Ins. companies really can suck sometimes :P

Title: Re: MRI/MRA Denied!
Post by Donna_D. on Dec 12^th, 2003, 4:09pm

Gregg,

Paigelle has given you some very valuable information. I think that (if you have the time) you should continue to fight to get the MRI/MRA approved even if only to create an example to the medical staff of the insurance company.

This thread, like a few others recently, has brought up issues regarding insurance.

WHY DON"T WE HAVE A BATTLE PLAN? WHERE ARE OUR GENERALS!! WE ARE SENDING PEOPLE UNARMED INTO BATTLE WITH THE INSURANCE CARRIERS.

I think we need to create a place either here or over on CH.org where people can list thier insurance problems and people like Paigelle and myself (and others lurking about) who are seasoned veterans of the insurance war can help people fight with proven methods.....forms, standard form letters, listings of state boards of insurance (I have one that includes all 50 states)...we need to strengthen our armor......

Let's discuss this............

Donna

Title: Re: MRI/MRA Denied!
Post by Paigelle on Dec 12^th, 2003, 4:12pm

on 12/12/03 at 16:09:44, Donna_D. wrote:

I would be more than happy to wage this war! Let's get it started Donna.

Title: Re: MRI/MRA Denied!
Post by Little Deb on Dec 12^th, 2003, 4:32pm

That is a great idea guys!

Fortunately, I have had no problem getting an MRI or CAT scan, last year, and getting another one next week.

Wierd how some suck and others don't.

Knockin' on wood......little deb

Title: Re: MRI/MRA Denied!
Post by LasVegas on Dec 12^th, 2003, 4:38pm

You girls are great, much thanks. Please advise here or email me with any form letters, ideas, etc and I will gladly make an example out of these bureaucrats. I was diagnosed (self-diagnosed) prior to my neuro visit and had to educate her. She is aware of the drooping eye, nasal congestion and temple pain at the Trigeminal nerve sites of the head and other symptoms that are common. She prescribed me what I asked for (o2, Verap, Pred and Trex) and in the dosages I requested, but as for the MRI and MRA, i'm in a battle without my armor. If you have ideas of how to obtain armor and perhaps some troops to recruit, I will gladly fight, just not prepared to lose alone.
Gregg in Las Vegas

Title: Re: MRI/MRA Denied!
Post by OneEyeBlind on Dec 12^th, 2003, 5:13pm

Donna, if you form a comittee for insurance problems I would like to volunteer to help. I had started documenting some stuff for the PA/NJ chapter.

Thanks !

Title: Re: MRI/MRA Denied!
Post by Paigelle on Dec 12^th, 2003, 5:29pm

Well, let's start forming. I have been downloading forms from my mom, who is working with insurance now at her office. I can handle the southeast and if Nancy wants to help, then we can cover the whole east coast. Let's get everything together and get this rolling. Maybe I can put my insurance knowledge to some good use.

Title: Re: MRI/MRA Denied!
Post by eyes_afire on Dec 12^th, 2003, 7:53pm

Hi Las Vegas, you're not alone.

Insurance companies only care about their profit margins. They don't care about your CH unless it's gonna cost them lots of money... then they don't even wanna know you. To answer your questions based on my own experience:

1. To rule out other things that might get physicians in trouble.
2. I've never had either.
3. There is no CH expert in your insurance company. Insurance companies are mostly accountants, claims adjusters, and telephone operators.

I'm sorry, my cynicism is showing.
I hope your episode ends soon.

--- Steve

Title: Re: MRI/MRA Denied!
Post by Cerberus on Dec 12^th, 2003, 8:56pm

1. To rule out any other potential problems, complications, and causes.

2. Those of us who have had nominal success with insurance companies.....................BITCHED A GREAT DEAL .............and had help from the doctors (least I did)

3. NO ONE , it is hightly doubtfull anyone at the insurance office even has clusters let alone knows anything about em.

hope that helped :D

Ramon

Title: Re: MRI/MRA Denied!
Post by Donna_D. on Dec 12^th, 2003, 9:28pm

To all interested parties:

Send me an e mail if you are interested in this project.

Smileyone1968@aol.com

After the newsletter is out for this quarter I think we can make some real headway very quickly. All of this would need to be proposed to the OUCH BoD of course.

Put your thinking caps on!!

Donna D

Title: Re: MRI/MRA Denied!
Post by Lori on Dec 13^th, 2003, 1:13am

$50 co-pay with an HMO?!?! That sure seems high for an HMO. I only pay $20 with a PPO and I don't have have hardly any restrictions or problems with going to see whoever I want without referrals. Such a shame. Good luck to you, nothing to add, everyone has given such great advice.

Title: Re: MRI/MRA Denied!
Post by forgetfulnot on Dec 13^th, 2003, 1:30am

TNW, way have an effect

Lee.............

Title: Re: MRI/MRA Denied!
Post by Paigelle on Dec 13^th, 2003, 8:51am

on 12/12/03 at 21:28:42, Donna_D. wrote:

Okay Donna, I am ready. I am not working right now, so this will be great for me to do. Plus I will like I am doing something great for my friends. I have letters and an ICD code book here. If anyone wants to help I can't get everyone a copy of the book. I also have a list of insurance commissioners for each state. On top of that I have contact names for some major insurance companies.

Title: Re: MRI/MRA Denied!
Post by don on Dec 13^th, 2003, 9:18am

Quote:

The best thing that could be done is OUCH could offer seminars for educating the medical profession on this condition.

Check in at the OUCH site.

Title: Re: MRI/MRA Denied!
Post by thomas on Dec 13^th, 2003, 12:51pm

Bean counters strike again - they obviously have over-ridden the hypocratic oath.