This is a question I get all the time. Your health insurance carrier has guidelines that need to be met in order for a scan to be approved. Your health insurance carrier has their own doctors or medical directors to review the precertification of an advanced radiology scan. Sometimes a denial can simply mean your doctor did not submit any or enough medical documentation.
If your doctor still feels your denied scan is medically necessary, he/she can request a peer to peer on a conference call with the doctor/medical director of your carrier and by the end of the call will have an updated result.
Understanding Radiology Categories:
I would like to go over the two types of radiology categories to help understand why your health insurance carrier would suggest a different radiology scan than what your doctor suggested.
- General Radiology Scans are ultrasounds (pictured below) and x-rays that show on the service what could be wrong. These typically do not require preauthorization and are less in cost.
- Advance Radiology Scans are more in depth and provide 3D images. These scans include MRIs (pictured below), PET scans, and CT scans. Advance Radiology Scans normally require preauthorization and are more in cost. In both cases please check with your health insurance carrier to check if there is a preauthorization required.
When Advance Radiology Scan Is Not Medically Necessary:
There are times when doctors request a scan that is not medically necessary. I have provided three examples where advanced radiology was not needed.
- I had a doctor request an MRI because a patient had symptoms of gallstones; however, the MRI denied.
The doctor did not perform an ultrasound that could provide the same information. The ultrasound is $200 verses $2000 for an MRI. The patient had a large deductible; therefore, the patient would be responsible for the entire amount of the scan. The ultrasound did not require a preauthorization and the patient could get the ultrasound that day. Needless to say, the patient did get the ultrasound. The doctor got the results needed to take out the patient’s gallbladder.
If the ultrasound did not pick up any gallstones, an MRI would be needed because there might be an underlying issue. In this case the patient did no need this. The patient saved $1800.
- My dad sprained his hand and the doctor contacted his health insurance carrier to preauthorize an MRI, which immediately denied because my dad did not have 6 weeks of conservative treatment such as physical therapy. Once he completed the physical therapy and the pain was the same or worse, an MRI would be approved. In his case the physical therapy helped and he was fully healed. Therefore, this saved my dad a lot of money.
- The last example is my own. I have chronic sinusitis. The doctor ordered a CT scan to see if surgery was needed, which got approved. My doctor prescribed oral steroids to take for two weeks. Then ordered another CT scan.
My health insurance carrier denied the authorization and rightfully so. The first reason was because I just had a CT scan two weeks prior. The second reason was that oral steroids are a temporary relief for chronic sinusitis. However, the doctor still sent me for the second CT scan. I nor did my health insurance carrier paid for the CT scan because I went in-network.
Two Important Points to Remember
1. Make sure you stay in-network. Your health insurance carrier has a contracted rate with that provider and you cannot be charged beyond that rate; whereas, as out-of-network provider can charge as much as the provider wants.
2. Also, please make sure you do not sign a waiver for an in-network provider that states, “If my health insurance carrier denies or does not pay, I will pay.” That means if your carrier denies your scan, you are liable for the entire cost.
Hopefully, this will help understand why your MRI, CT, CAT, or PET scan denied. I know this can be frustrating but calling your insurance company to scream at the representative is not productive. I encourage you to get the information on the denial and call your doctor to see what step your doctor will take next.
I want to hear from you. Tell me a time when your insurance company denied your scan and what was the outcome. #stayhealthy