How do I get Medicare Pre-Approval for This?

[athena53]

I'm due for a mammogram and two developments have kicked me into the high-risk group. Maternal Grandma died of breast cancer but she was 74, overweight and smoked most of her life. Mom died of BC but she was 85, although it was a recurrence from when she had it at 78. My sister, age 63, had a negative mammo in March, was paranoid (Mom's had been negative) and got an MRI. They found a 2 mm cancerous lesion and my sister got a double mastectomy. Well, she's a doctor. That's how she dealt with it. After that news our cousin (in her mid-40s, same grandmother) decided to have a lump checked out. Cancerous. Will need aggressive treatment but she should pull through. Sister, BTW, tested negative for all 30+ genetic markers they looked at. Fat lot of good that did her.

So- I went straight to the office of the High Risk Breast Clinic. I have an appointment for late October, first a consult with them, then a bilateral diagnostic mammo (they tell me it's more precise) and, if ordered, an ultrasound. They tell me they ran the consult through Medicare and I should owe nothing but that I need to find out if they'll approve the two tests.

Anyone know where I start? My guess would be that it would depend upon the all-important coding and how can Medicare predict how the claim will be coded? If someone I talk to says it's "medically necessary" can I trust them? Will they give me a determination in writing?

I've got plenty of time but need to get this done. Thanks!

 

[MBSC]

Original Medicare does not pre-authorize diagnostic services. You can call 1-800-MEDICARE but the CSR should not use statements like "will" be covered if they have been properly trained. Regardless of what they say, the provider will have you sign an ABN (Advance Beneficiary Notice) when you arrive stating you are responsible for services Medicare does not cover.

Medicare ABN: https://www.medicare.gov/claims-and-appeals/medicare-rights/abn/advance-notice-of-noncoverage.html

Diagnostic mammography denials are usually because supporting documentation was not attached to the claim. There are ways for the provider to submit additional documentation for reconsideration. Medicare also has an appeals process. If you purchased a Medicare supplement from an experienced local agent, the agent will have years of experience dealing with Medicare billing issues on behalf of their clients, not just supplemental issues.

 

[athena53]

Thanks! So, it sounds like it's up to the provider to make the case. I did do some searching and found that the cost of ultrasound, if it's necessary, is $250-$480 in our area. I figure they'll at least pay for the cost of a regular mammogram (I'm due for one) and if I have to pay extra for the diagnostic and 100% for the ultrasound I'll do it anyway. It is good to have options.

 

[MRG]

Different but something the same.

I had extensive balance testing done a few years ago and the facility gave me the codes they would be using. Called insurance and they told me exactly what was covered.

I assume that the provider was doing this for their benefit as you were in there four hours. They didn't want to chase folks around collecting money..

 

[athena53]

Different but something the same.

I had extensive balance testing done a few years ago and the facility gave me the codes they would be using. Called insurance and they told me exactly what was covered.

Ah, the actual codes would help. I'll see if I can find them out beforehand.

The other thing I've found is that many providers magically come up with the out-of-pocket amount just before they start anything- so they can swipe your credit card first!

 

[audreyh1]

Does a doctor's referral for the diagnostic mammography make a difference? Would that be part of the supporting documentation needed?

 

[Moemg]

I just checked my records . I had a bilateral diagnostic mammogram a month ago . Medicare covered all but $24. I have also had breast ultrasounds in the past and they were almost totally covered with my secondary picking up the additional . The only documentation I needed was a Dr.'s note .The thing is with diagnostic mammograms they have you wait which sometimes feels like forever until they get final approval on the films . This is routine but the first time it got me very nervous.

 

[athena53]

Does a doctor's referral for the diagnostic mammography make a difference? Would that be part of the supporting documentation needed?

I wouldn't count on that- I had a doctor's order for routine bloodwork a few months ago and Medicare didn't cover about $800 wirth of them because they weren't "medically necessary". That included a lipids panel (and my total cholesterol is over 200 and always has been) and an Hba1c (and my fasting glucose has always been a little over 100). So- nothing exotic, and I had history that justified it. I ended up owing nothing, apparently because the lab didn't have me sign an Advance Beneficiary Notice, but it was odd to me that Medicare would have deemed those very ordinary tests "not medically necessary".

 

[braumeister]

I wouldn't count on that- I had a doctor's order for routine bloodwork a few months ago and Medicare didn't cover about $800

That happens once in a while, often due to a simple coding error.
My supplemental coverage has always paid it, but once I appealed the mistake and Medicare paid it after they got the codes changed by the provider.