Pre-Authorization Denials

[24601NoMore]

Hey, everyone. Wondering how many of you have had issues getting pre-authorizations for medical tests or procedures approved?

I need a MRI for the (likely) shoulder injury that happened when I got the first COVID shot. The pain is moderate and enough to wake me at night. So, I went to my Orthapedic Dr who did all the tests he can do. Need some imaging to figure out what's going on.

They submit for the MRI pre-authorization. Takes forever (almost 2 weeks) to hear back - DENIED. Here's the kicker..it's denied because I "haven't completed a 6-week trial of doctor prescribed treatment. Supported treatments include (but are not limited to) medications for swelling or pain, physical therapy, and/or oral or injected steroids".

So, the Doctor should just do random injections into my joint (possibly causing further issues), or I should do random PT when the PT therapist would have no idea what the underlying issue is? Or, I should just "suck it up" and take steroids or some other drugs for 6 weeks to see if that helps? Seriously?

There's NOTHING in my healthcare contract (I looked) that says you need to "complete 6 weeks of doctor prescribed treatment" before you can get a MRI. I plan to emphasize the heck out of that point in my appeal.

Turns out the company doing the denial is apparently a third-party, more evil than Satan and all his minions corrupt piece of garbage from the seventh level of hell called Evicore. Do a google search on these demons. People with Stage 4 cancer who need something..DENIED. In a car accident with a bone literally sticking out of my back - need surgery..DENIED - "not medically necessary".

Lots of talk online about a class action lawsuit against Evicore. Turns out many larger insurers (BCBS, Cigna, my own provider [Priority Health] and more) all use them. I even came across a story where a large employer moved all his hundreds employees off BCBS (I think of NH), paid $70K MORE a year for a plan with a different insurer, because of all the problems with Evicore and their denial of services that were obviously medically necessary.

Even more heartbreaking - Evicore is being sued by a lady who got denied for a MRI, then months later when it was finally approved after multiple appeals - they found her back pain was being caused by a tumor that had spread to multiple discs. She's now paralyzed for life and in a wheelchair, when earlier treatment would have prevented that extensive damage from occuring. All to save on approving an MRI for her. I hope she wins tens of millions in damages.

Also heard that Evicore "peer to peer" reviews if you contest their denial happens with Doctors with totally random and rarely applicable skills. Need an Oncology review? The Evicore Doctor talking to your own doctor might be a speech pathologist. Or an OBGYN, instead of an actual Oncologist on their end. Yeah, I actually saw lots of reports online of that reportedly happening.

Has anyone else had this type of issue or run into these evil morons from Evicore? I realize imaging is generally hard to get approvals on. But in this case, I have a $7,000 deductible that I'll never, ever hit unless I get hit by a bus or come down with a horrible disease. So, I'll be paying for the MRI totally out of pocket ANYWAY! The only thing their approval gets me is the "contracted" vs "cash" price. Probably a net difference of $2-250 or so, and what I pay if I have to do "cash" will not apply against my super massive deductible.

While the $2-250 difference on the MRI isn't super major, I do worry..what happens if wife or I ever have a more serious issue that requires surgery, life saving treatment of some sort, etc? This demon spawned company is out there regularly denying approval hoping people give up and go away. So you then have to appeal and fight..and by then, it may be too late and your health has deteriorated further - perhaps permanently..or perhaps to the point of fatality. This is candidly terrifying and doesn't seem to improve any on Medicare who I believe plays the same cost-savings games. Man, I miss the corporate sponsored healthcare. It wasn't perfect, but 10,000X better than the "A"CA.

Appreciate all insight, horror stories, etc. I'm sure there are many.

[braumeister]

Quote:

Originally Posted by 24601NoMore This is candidly terrifying and doesn't seem to improve any on Medicare who I believe plays the same cost-savings games.

Very sorry you have to go through this, but FWIW I've never had anything denied by Medicare, and there have been quite a lot of procedures over quite a few years (including MRIs). It's a very good system IMHO.

[disneysteve]

It is completely normal for MRIs to need prior authorization and they typically do require a course of conservative therapy first. While this can be incredibly frustrating when the test is justified, it also prevents a ton of unnecessary scans and saves the healthcare system millions of dollars a year. I can't tell you how many patients come in saying, "I stubbed my toe this morning. I want an MRI this afternoon." Far too many people think MRIs are magic and "It's covered so I don't care what it costs."


It's pretty much SOP for companies to deny the initial request hoping to discourage people from appealing. The appeal process is usually pretty straightforward although does occasionally require the provider to get involved and speak one on one with their medical director to get the approval. My staff took care of most cases and I got on the phone for the rare ones that needed me.


In your case, if your plan doesn't even cover the scan, I'd just bypass all of the BS and set it up on your own. Call around and get prices from your local imaging centers. Avoid the hospital-owned ones as they generally charge more. If you call and say you need an MRI of your shoulder and want their best cash price, there's a pretty good chance that you'll find a better deal than the "contracted" rate. If you live in an urban area and don't mind traveling a bit, check places outside of the city as well.


I'd also keep calling and bugging the ordering doctor to ask if they've done the appeal yet. Two weeks for that initial denial was way too long. Somebody wasn't on top of things if it took that long. 3-4 business days is generally reasonable.

[zinger1457]

I had something similar happen to me with shoulder pain, not from the Covid vaccine but from the Shingrix vaccine. My regular family doctor thought they might have nicked a tendon when giving the shot and felt it would heal on it's own over time. I bought a 'tens unit' and it seemed to help. It was painful initially, especially when doing activities like golfing but it did eventually go away, took maybe 6-8 weeks. Maybe that's what your insurer hopes will happen and the test won't be necessary.

[Exchme]

Every insurance says something about "medical necessity" and that's where they get you by saying you simply haven't shown the necessity without jumping through their hoops first. You can imagine that there would be people that would abuse the system and want exotic tests and treatments for everything, so you can sort of see where they are coming from, but when it just becomes the magic words to say to deny claims, it's annoying.

Even with employer based coverage, we've found that it's often cheaper to shop around and ask what the no insurance cash price is. It's often pretty darned close to or even below the insurance company's "contract" rate. As you say, you probably won't hit the deductible anywayand at some point you just want to have the diagnosis so you can tell if PT is enough.

[disneysteve]

Exactly the reason for the rule. Most minor issues heal given time and the MRI makes no difference. 80-85% of back pain resolves within 4 weeks, for example.

[24601NoMore]

Thanks, gang. I did call around and so far at least have not been able to find a cheaper cash price than the contracted rates..

It just irks me no end.."we have NO IDEA what's causing this, but instead of doing an MRI to find out, try this random series of things that could make you worse off. Oh, and do it for at least 6 weeks while the pain keeps you up at night and pretty much ruins your entire life during the period. Thanks for calling and have a nice day".

It makes ZERO medical sense to randomly inject steroids or say I need to do 6 weeks of PT if they don't even know what the underlying cause is. Let's say it was cancer (it's obviously not, but as an example). Would PT help? Nope. Steroids? Nope. And even with my current problem..would PT help? Probably not, because the PT guy (and I have a really good one) would have NO IDEA what he's trying to fix. Just "pain". What's causing the pain? No idea, because we don't have an image to determine what the cause is.

I get that people often want to do tests that aren't "necessary". But it should be up to the front-line Doctors to determine, not some third-party, probably outsourced outside the USA company to determine in lieu of the actual Doctor who's treating the patient.

Like I said..this is minor in the grand scheme of things, but makes me absolutely terrified that I'll run into huge issues if we ever actually need something like surgery or a hospital stay..there are literally hundreds of stories and dozens of BBB complaints out there against Evicore. Many of the people far worse off (denials on treatments for PET scans for people with Stage 4 cancer, for example)..

[24601NoMore]

Quote:

Originally Posted by disneysteve Exactly the reason for the rule. Most minor issues heal given time and the MRI makes no difference. 80-85% of back pain resolves within 4 weeks, for example.

This has been going on for 2 months, with zero net change. In fact, it seems to be getting worse.

It's not apparently just going to resolve on it's own.

PS: If the expectation is that it's just going to heal given time, why the insistence to do 6 weeks of totally random treatments that could in fact make the situation even worse?

[24601NoMore]

What probably irks me the most is that I'm paying one hundred percent for this test out of pocket regardless of approval or no approval.

My insurer will pay ZERO, even if they were to approve.

So I simply can't fathom what the issue is. Their cost is ZERO, either way, because it's all part of my massive, $7K deductible that I will never hit unless I come down with some horrible disease or get hit by a bus.

[Koolau]

I ran into this with my knee. I had a fall and felt something "tear." Didn't hurt at the moment but the knee was soon inflamed. "Cheap" X-rays didn't show anything. So doc wanted MRI. He had to fight with the (otherwise excellent) insurance company. They insisted I wait a month and try anti-inflammatories (tylenol is just about all I tolerate - can't do ibuprofen, etc.) So, finally, got the MRI - guess what? Small torn cartilage around knee. Doc said surgery would work, but lets try PT first. I was skeptical, but it worked. Why didn't Ins. co. suggest that first - who knows.

Anyway, MRIs seem to be the one thing medical insurance companies hate most. YMMV

[teej1985]

Curious, how did you injure your shoulder while getting the shot?

[Dash man]

My insurance, Aetna, uses Evercore. I haven’t had any problems with them personally. I had an MRI last month for a follow up of a back problem I’ve had for years. I also get ablations a few times a year that are never denied after I went through a series of facet injections a few years ago. All these requests came from a Pain Management specialist and not a GP. In three months I’ll be on Medicare Plan G, so hopefully I won’t have to seek approvals at all.

[24601NoMore]

Quote:

Originally Posted by teej1985 Curious, how did you injure your shoulder while getting the shot?

I can't 100% "prove" that it was from the vaccine (shot 1), but the problem started literally the day after I got the first shot, in the same place I got it and has lasted since.

I think the person administering it hit something. She seemed to dose me VERY high on the shoulder - a lot higher than she should have. I assume she hit my bursa, a tendon, a nerve or something. No idea what, but it's pretty direct cause-effect, and I didn't do anything else that could have caused the current problem, like try to tackle a pro football player, wrestle an alligator or anything similar.

There's actually something called SIRVA - Shoulder Injury from Vaccine. Happens most often if they vaccinate you (not just COVID vacc but any vacc) too high. Who knew?

Turns out I also have an abscessed tooth I've dealing with for a week now. Couldn't get in to an Endodontist till Tues. The only good news is the shoulder and arm pain has made me all but forget about the pain from the abscess. (I've also been taking 200 mg Advils around the clock for the abscess and eating them like Skittles..strangely, it's not even TOUCHING the shoulder & arm pain, although it does seem to be working for the abscess pain). That's how moderately bad the shoulder/arm is..it's not "severe" bad, but enough to wreck my day most days and wake me at night.

[disneysteve]

I hope you get some relief soon, MRI or not.

[Clover5]

This might be useless info but if you leave near the Mexican border an MRI will run you about 100USD SOB.

[Sunset]

OP - I've always felt it's a weird system where my Doctor says I need something, and then I have to get approval from some minimum wage clerk at the health plan before going ahead with it.

As for MRI, I wanted one, so I phoned around (years ago) and found out the cash price was twice my super lousy health insurance contracted rate.

When the MRI person finally understood I needed to know the actual price as I was going to be paying all of it, except $200, she finally got on board and told me the prices. Prior to that she was "Don't worry insurance pays it"

[Scratchy]

If you decide to have the MRI without authorization (and I'm not making a recommendation either way on this), I suggest you check with your surgeon to make sure the MRI facility you select is acceptable to him. There is wide variation in quality of MRI shoulder performed and in its interpretation. Your surgeon may prefer you have your imaging performed and interpreted by specific radiologists.

If surgery is being considered, I recommend you diligently seek out the best shoulder surgeon available to you in your health plan. Shoulder surgery and recovery tend to be grueling processes for the patient, and outcomes are highly dependent on the judgement and technical skills of the operator.

Best wishes for a good recovery.

[24601NoMore]

Quote:

Originally Posted by disneysteve I hope you get some relief soon, MRI or not.

Thanks..appreciate it. Has been going on for 8+ weeks now and really can ruin your day..

Quote:

Originally Posted by Clover5 This might be useless info but if you leave near the Mexican border an MRI will run you about 100USD SOB.

Good info but am in the Midwest..

Quote:

Originally Posted by Scratchy If you decide to have the MRI without authorization (and I'm not making a recommendation either way on this), I suggest you check with your surgeon to make sure the MRI facility you select is acceptable to him. There is wide variation in quality of MRI shoulder performed and in its interpretation. Your surgeon may prefer you have your imaging performed and interpreted by specific radiologists. If surgery is being considered, I recommend you diligently seek out the best shoulder surgeon available to you in your health plan. Shoulder surgery and recovery tend to be grueling processes for the patient, and outcomes are highly dependent on the judgement and technical skills of the operator. Best wishes for a good recovery.

Great point. My Ortho Dr's office is in the same building as an Imaging company that they prefer. I'd already been leaning toward them and as long as I can get a decent price will probably go that way.

In other news, I looked up the name of the "MD" who signed the denial letter in NPPES. That's apparently the national registry of ALL healthcare providers. Turns out there are 8 people in America with that name. NOT ONE is in a discipline that would be qualified to render a medically sound opinion on my case. Here are the areas of expertise listed: 1) Marriage & Family Therapist. 2) Psychologist. 3) Occupational Therapist. 4) Clinic/Center Primary Care. 5) Registered Nurse [obviously not this person as the letter was signed "MD", not "RN"]. 6) Social Worker. 7) Speech / Language Pathologist. 8) Advanced Practice Midwife.

NOT. ONE. Orthapedic Dr or anyone in a related discipline. I'm absolutely going to demand my health insurer tell me the medical qualifications of the person who wrote the denial letter and also ask them to point me to where in the contractual documents governing my plan agreement it says I "need to complete 6 week trial of Doctor prescribed treatment" prior to getting a MRI - because I know for a fact it's not in there. I read the entire thing yesterday.

Like I said..it's not the cost (probably an extra $1-200) that's the issue for me, although being ER'd every penny counts. It's the damned principle of paying nearly $14K per year (before the recent legislation changed and we now get subsidies bringing it down closer to $8K) in premiums and them just doing everything they can to prevent me from even using what I'm paying for. That's a LOT of money and to not be able to even USE the insurance - even though I'm paying 100% of the cost either way (approved or denied) just frosts me NO END.

[24601NoMore]

Well the good news is that I found a MRI provider that my Dr likes who has a net cost difference of < $50 between contracted and non-contracted (ie: cash) prices for the two MRIs.

That said, the $600 or so (combined) that I'd pay for the two (cervical spine and shoulder MRIs) wouldn't go against my deductible. Not that I'll ever reach my deductible anyway unless a catastrophe happens, so there's that.

I guess my bigger issue is that this requirement for 6 weeks of "Dr. prescribed trial treatment" (PT, injections, etc) was not documented ANYWHERE in the contract. Or the marketing materials. MRI are "covered with pre-authorization". What they DON'T tell anyone is that pre-authorization includes things that many would not consider "Medically Necessary" (random PT..random injections..randomly prescribing pain meds). Instead, there are these hidden requirements that don't come up until you go to get pre-authorization, and then it's...SURPRISE! There's these ridiculous, unachievable hoops you need to jump through in order to even USE the insurance you're paying to get! And what's even WORSE - even jumping through the hoops doesn't "get me anything" other than credit against my deductible and a slightly better price, because I'll never hit the deductible and the insurance company doesn't have to pay even one cent ANYWAY!

I did look up other insurance companies in my area as I think we can switch on the "A"CA until mid Aug, but none of them appear to be overall better. Most require PCP referrals to see a specialist (mine doesn't)..deductibles are similar or higher..and the real kicker - no other network takes many of our large # of doctors and specialists. So, I'm stuck having to jump through stupid hoops like spending $3,600 (6 weeks of 3 visits per week PT @ $200/visit) to get a $300 (literally) MRI approved. I'm obviously not going to do that so won't put the MRIs through on my insurance to get the deductible credit even though I'd still be paying 100% of the slighty lower, contracted cost, but what other undocumented surprises and unachievable obstacles am I going to run into with these guys as my insurance company?

Terrifying stuff. Boy, do I miss corporate sponsored healthcare. It wasn't perfect, but it was LIGHT YEARS better than the "A"CA plans.

[disneysteve]

I'm glad you found a place to get the MRI.


I have to tell you, though, that everything you've described is totally normal. It is not your specific insurance company. You've described the system with every insurance company I've ever dealt with, whether commercial or government-sponsored. Requiring prior auth for an MRI and that prior auth often relying on 6 weeks of conservative therapy is very much standard practice for most every insurance company.