Pre-Op MRI Denied by Aetna/Evicore

[chrisabbott]

Surgery for my 3.1 cm tumor is scheduled for June 13th - I just got a letter saying Evicore had twice denied preauthorization for a CT & MRI saying it is not approved because I've had one before.... 

My letter said the physician involved in the decision could be reached at ### - when I called, they refused to let me speak with the physician and couldn't give me details as to why they didn't think I needed an MRI for my surgeons to plan my treatment.  They wouldn't send me copies of anything or explain why the office of neurosurgeons that request these things all the time, and had assured me they don't get denials for this type of treatment/surgery - should have to make themselves available for a "peer to peer" call just to get approval for something that is blatantly obviously required. 

I want my scans done, but I also want to do something to help avoid the horrible stress being inflicted on me and others + wasting doctors' time.  They denied my husband's orthopdedic surgeon's request for an MRI of his shoulder saying he should have 6 weeks physical therapy first.  He had a complete rotator cuff tear and needed surgery - Tricare covered the MRI as primary because our other ins had denied.  I followed up with Aetna and told them they were wrong, and they reversed the decision with no new information or coding from the twice denied surgeon.  They are for sure routinely denying procedures, and requiring additional info from doctors in hopes people will give up or someone else will pay.

I hope you don't mind me blowing off steam here - to top it off, my neurosurgeon's office called me yesterday but I was literally being squished in a mammogram so I missed the call. I called back but too late - now I don't know if it was due to this or for something else and I'm starting to go pretty crazy over all of this.  My job involves travel and scheduling meetings well ahead of time so it's an added stress if I can't line up my medical appointments so I can book my work around it - the insurance denials have made me angry.  My employer is paying premiums as well as me, and I didn't get any work done yesterday largely due to being on the phone with Aetna & Evicore for a couple hours and not being able to think of anything else.

[Patti]

Oh I feel for you. My first surgery (19 years ago) never questioned any procedure and there was always someone available for me at the doctor's office to help. Fast track 15 years later-insurance trouble, peer to peer reviews that were supposed to happen but the doctor didn't do his end. I can't (don't want to) remember all the difficulties, but the doctor's lack of communication was the problem. That procedure was done (cyber-knife?) and i will never go back there again. I get my MRIs done up here now and keep an eye on it with a local neurologist. The stress of it all was so unreal! Good luck! It will all work itself out but this stuff is the last thing you need!

[chrisabbott]

thank you - I got a call from the surgeon's scheduler today saying this morning, the insurance company reversed their denial.  She said they'd often been denied once, but not twice and had been hearing from other clinics about the increased frequency of insurance denying twice then requiring a peer to peer review.  Maybe my 2 hour call yesterday wasn't a waste of my time after all.

I looked up Evicore's policies on this, and their peer to peer reviews boil down to their physician who has not met/examined me, educating my surgeon on the need to minimize using tests such as MRIs.  A disgraceful waste of my doctor's time - I would understand if this was my GP requesting an MRI for a sore wrist without first trying other solutions, not a neurosurgeon scheduling an MRI to plan brain surgery.  If the doctor didn't mess up the original preauthorization request, the insurance companies should not be adding layers of hoops for them to jump through.

[Patti]

So glad it worked out! Good luck with everything. Keep us posted!

[chrisabbott]

Will do!