HomeHealth InsuranceWill Your CT or MRI Scan be Denied?

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Will Your CT or MRI Scan be Denied? — 33 Comments

  1. I am going through this right now. My CT scan was scheduled for tomorrow at a hospital and my insurance company did not authorize so the hospital cancelled my appointment. Doctor’s office talked with the insurance company and provided them with whatever they asked for. I have to wait till Monday to find out whether or not they will authorize. And if not I will have to get x-ray or ultrasound done.

    • I am so sorry. Hopefully, they will approve the request now that they have additional information from your doctor. Ultimately, they may approve the test but they may require that you have it done at an outpatient facility instead of a hospital. The cost difference can be huge!

  2. And if they see something in those tests, the insurance company will have the evidence that a CT scan is needed. So I have waited over a month now already and maybe I will have to wait another month or longer just to find out whether or not I have cancer. That is so messed up. Why are they asking for evidence for the need of this test? The test is to find out what is wrong. How can anyone know what is wrong without the test result? I have low wbc (it was Normal in January) and I have 7-8 swollen lymph nodes in my neck for over 5 weeks now. Isn’t that enough reason for a concern? I am so stressed already and the insurance company is making is worse.

    • Oh my goodness, I’m sure this is very stressful for you. Please be diligent about following up with the request. Unfortunately, there is often a disconnect between patient care and the insurance companies who pay for it. I wish you the best of luck.

      • Thank you! There is a 90% chance that I do not have cancer. I am trying to think positive. It’s just that I was so close to finding out and the process delayed last minute. My doctor and his staff are very helpful so I am sure it will work out eventually. Hoping for the best.

  3. I’m running into issues with this as we speak. Anthem BCBS apparently uses a secondary company to determine whether a CT scan is needed. I have a softball-sized mass in my abdomen that was identified in an x-ray, after I complained about consistent abdominal discomfort that’s been going on for months. This company determined that a CT scan was NOT NECESSARY. My doctor now needs to contact the company to have a peer-to-peer review with their doctor about why it’s necessary for me to have this scan. If I hadn’t just spent the last week not sleeping while worrying about this, I’d laugh.

    I would never, EVER use this insurance company by choice.

    • Heather, I am so sorry to hear this. It is very frustrating when insurance companies get in the way of appropriate medical care. I’m sure your doctor will advocate for you during the peer-to-peer review. I wish you the best of luck and I hope you get a speedy resolution to your problem. Thank you very much for reading and sharing your thoughts.

  4. Denied ? $1700 a month that’s hardly used . One of these days everyone is going on strike ! They make a fortune! All about $$&& I bet no one in there family gets denied . They should trust the Dr. they need to be sued by anyone that dies because of being denied. Life is hard enough bring in pain and being denied of a test because of $ is a crime ! KARMA

    • Yes my wife died waiting for pet scan after haveing CT scan. Because insurance denied..they saw spots on lungs ended up in er said pneumonia turned to sepsis then septic shock she died 11/24/17 she had been seeing a lung specialist but was waiting on insurance to allow pet scan

  5. Yes my wife died waiting for pet scan after haveing CT scan. Because insurance denied..they saw spots on lungs ended up in er said pneumonia turned to sepsis then septic shock she died 11/24/17 she had been seeing a lung specialist but was waiting on insurance to allow pet scan

  6. So my son had an MRI 3/21/18. We just received notice on 3/30 that it was not approved by insurance pending further information. The MD office sent the PA the same day the MRI was completed-although this test had been scheduled for over 2 months. If insurance denies the MRI (which also included sedation with anesthesia) will we be responsible for the mri, sedation, and anesthesia?

    • Hi Sarah,
      Each insurance company has their own policies regarding prior authorization, but the key word is “prior”. Ideally, you want the request submitted in enough time to allow for an appeal if the procedure is denied. I’m crossing my fingers on your behalf. If it is denied, be sure to solicit the help of your physician to write a strong appeal letter.

  7. my son just turned 17 and has no insurance. the state chip program recently dropped him.
    he needs an MRI, can we pay out of pocket?

    • Hi Joyce,
      I am sorry to hear that. You can always pay out of pocket but MRI scans tend to be very expensive. I recommend you talk to his doctor to review your options. If you must pay out of pocket, be sure to call around to various outpatient radiology facilities because price can vary greatly. Check out my article, “Shopping for Healthcare Deals” for more information and good luck!

  8. My insurance company has denied my MRI. Twice now and my story is quite different! I’ve had 3 drs tell me I need a mri and insurance is being very difficult to say the least!! My neuro surgeon mailed me the denial letter and asked me who I pissed off and said they have never heared such ludicrous reasons for the denial! I have had the X-ray and CT already and went thru a painful physical therapy insurance made me go to.( Which I know they always have you jump thru hoops first ). I am no longer able to work at all and the pain and symptoms are getting worse! The insurance company stated it wanted me to quit smoking before they would approve an MRI! Yes you read that right! I know my surgeon wants me to quit but insurance saying I have to and take a urine test proving it ? Also they questioned my results from CT and wanted my dr to explain the results? Which he did ! I called my insurance company and they totally passed the buck and said it was my drs office who hadn’t submitted everything they requested. So they resubmitted it and I was denied again?? I have fragmented discs now and have Been diagnosed with all the major back problems ,stenosis. spondylthesis. Etc
    I don’t know what to do? I’m at a stand still and seems like I can’t get any help! And let’s not mention the fact that while I’m waiting I’m living in pain every day and cannot work and because of all the pill popping addicts I cannot get any help managing my pain either!

    • Teresa, I am so sorry that your insurance company is being uncooperative. As a physician, it really angers me when individuals with no medical training override a physician’s recommendation. Please talk with your physician about filing an appeal. I hope and pray you get relief very soon.

      • I’ve been in contact with my neuro s office and in fact asked her to resubmit it after I called the insurance company myself after being frustrated from the first letter She said she would do it and then days later called me back and said she had bad news again. I asked her what I can do and where do I go from here and she basically told me good luck and she had exhausted all of her options!? She said I can try my husbands work and have them call the insurance company ? It’s not like they are a huge corporation or anything so I don’t think that would threaten them in anyway. I’ve been reading about insurance commission? And a external review?? I just don’t know how to go about doing that and also I’m so confused by the insurance Mumbo jumbo. Where exactly I’m at in the process? They say one thing then turn around and talk about another ? ? I thought the drs office does a pre treatment notification first ? Well the second letter says a final coverage determination cannot be made until and actual claim is submitted?? I don’t understand that part and my drs office and our conversation yesterday sounded like she was done with me? I wish I could post the letters. You really won’t believe ur eyes!

    • Teresa,
      I am very sorry for all of the difficulties you are having. As you and I are not in an advocate-client relationship, I am unable to provide you with specific advice. Please consider hiring a private health advocate in your city and I really hope you get this resolved.

  9. I am waiting for prior authorization for an MRI scan for my back. My insurance provider is dragging their feet so I called up the billing department at the hospital that I would have the MRI scan. I told them I was still waiting for my insurance company to approve it, but figured since I had not yet reached my deductible I was more than most likely going to be paying for the exam myself and decided I could just skip the middleman (insurance company) if the scan was within my price range. They quoted me $830 for the MRI and I said great, I can dip into savings and just pay for it out of pocket only to be informed that if I did this without having received prior approval that any procedure related to anything found in the scan would not be covered by my insurance. How is this even legal?!?!?!

    • Hi Judith,
      I am sorry that you are having challenges getting your MRI scan. It seems unusual (and unreasonable) that your insurance company would not cover procedures related to findings of the scan if you pay for it yourself, BUT there is a lot of small print in insurance company contracts that most don’t read. Therefore, I recommend that you speak directly with your insurance provider to clarify this matter. If they are taking a long time to approve the scan, you can ask the physician who ordered it to contact them on your behalf, particularly if your symptoms are worsening. I wish you the best of luck!

      • My primary had a peer-to-peer and they turned me down for the MRI. Will be going in for an X Ray and finger cross that something shows up that would compel my insurance company to let me have the MRI. What is laughable is they wanted to know what procedure I was getting, surgery, injections, etc… in order to justify the MRI. My doctor explained he could not authorize surgery, injections, etc without knowing what was going on in my back, which was why he needed the MRI in the first place. The whole system is madness!

  10. I am dealing with a similar issue as everyone else. My primary doctor ordered a MRI of my spine to determine whether my degenerative disc disease has progressed further. My last MRI which led to diagnosis of DDD was maybe three years ago, and at the time my neurologist said it hadn’t progressed to a point where surgery was a good option. Despite this, Cigna denied the MRI even after two peer-to-peer conversations with my doctor.

    I am now having debilitating pain and numbness throughout my entire body on a near daily basis that is getting progressively worse. My primary doctor has run blood tests to determine whether I have an autoimmune disease (rheumatoid arthritis, lupus, Lyme). These came back negative. I’ve had a nerve conduction study done to determine why along with the pain I had also lost feeing in my hands and fingers (questionable diagnosis by specialist of carpal tunnel), especially when I also experience this in my legs and feet. I’m also scheduled to see a rheumatologist in two months.

    The ridiculous part of this is that Cigna says that I haven’t seen the doctor enough in the past year and a half for this. (??) Even worse is that they now are REQUIRING me to see a physical therapist for an unspecified amount of time before they will reconsider. I CAN BARELY MOVE WITHOUT PAIN, AND THEY WANT ME TO SUBJECT MYSELF TO “THERAPY” THAT WILL NO DOUBT CAUSE EVEN MORE PAIN! For a documented CHRONIC CONDITION. What boggles my mind is that they will cover this, but not the MRI.

    Honestly, I just want to find out if my spine is causing the problem before my doctor moves on to further, more invasive and expensive tests for autoimmune issues. I just want feel better and be proactive with my health, and yet it seems Cigna doesn’t want to cooperate. I’m so frustrated.

    • Hi Kimberly,
      I am very sorry you are having severe pain. It is not uncommon for insurance companies to require “conservative management” of certain conditions prior to approving additional studies, such as MRI scans. While you are worried about physical therapy causing more pain, many individuals with chronic pain find that their pain improves with physical therapy. I recommend that you discuss this with your physician to ensure he/she doesn’t have any objections. If your symptoms are not improved with therapy, hopefully your insurance company will promptly approve the MRI. I wish you the best.

  11. I had a STAT CT done at an immediate care. The CT showed a lesion in the posterior fossa. I am now at day 5 waiting for my authorization for the MRI that the neuroradiologist recommended to have done right away. It is currently in peer to peer review. The doctor that ordered the MRI is my PCP. My PCP said he won’t do the peer to peer because he is not a neurologist and won’t be able to answer all their questions. What are the chances that Anthem BC will deny the claim?

    • Hi Susan,
      First of all, I am very sorry you are going through this and will pray for a good outcome re: the MRI results. I can’t tell you the chances Anthem will deny the request but, given the information you’ve provided, an MRI seems like the logical next step. You’d be surprised who’s involved in “peer-to-peer” calls. Often, the physician representing the insurance company is not a specialist in the area of question. I bet your PCP would do a fine job defending the need for the study. I wish you the best of luck.

  12. My mother was diagnosed by a Neurologist with severe Alzheimer’s disease. He ordered an MRI and EEG through the SAME hospital he works in. The Neurologist accepted my mom’s Medicaid Insurance. The Radiology Department however did not. We tried twice in person and twice they denied to see her on her scheduled day for the tests. We called the number for Medicaid and was provided with a list of In Network hospitals that accept Medicaid. We scheduled her MRI and EEG through one of the hospitals recommended by Medicaid. The hospital confirmed that they accepted the insurance. Close to the date of her appt, we got a call. The appt was cancelled because the Neurologist needed to be in Network and working through that hospital. We called the Neurologist and they indicated that the Primary Doctor has to Authorize the MRI and EEG through that hospital. We feel time is of the ESSENCE and we are back to square one. The problem is that my mom has lost her referral from the doctor for the Neurologist. She has a new Doctor and we do not know who she saw. Do we start from scratch and find a new Primary Provider? Do we have rights to have these tests Authorized due to her condition? Any guidance would be extremely helpful.

    • Hello Claribell,
      Wow, it sounds like you all have been through a lot trying to get the MRI and EEG. Pre-authorization is generally required by the insurance company, not the hospital. The hospital must have received notification from Medicaid that the studies would not be covered without pre-authorization, hence the call to cancel the tests. I am not sure why the neurologist needs to be in the hospital’s network. I would contact your mother’s new primary care provider and let him know you need pre-authorization for these studies. I would make sure this new doctor has access to the neurologist’s evaluation of your mother. That should give him all of the information he needs to obtain pre-authorization from the insurance company. Stay in touch with the insurance company to ensure things are moving forward. Be a pest. I wish you the best of luck.

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