How can I win this appeal vs. my insurance company?
April 6, 2015 2:47 PM   Subscribe

I have breast cancer. My health insurance company, which has paid out tens of thousand of dollars in the past two months with not a peep of protest, has now denied the $6000 genetic testing to determine whether I have the BRCA (and other) mutations. I am not really surprised, but I don't want to pay $6000 out of my pocket, either.

I am planning to appeal this decision, obviously. I will get my doctor's office involved in supplying a letter of medical necessity (or whatever it is they can do), and will write my own letter as well. It really does make fiscal sense for me to have had this test; without it I likely would have made the decision for more radical, more expensive surgery. I also found out as a result of this test that I do not have a genetic predisposition for the type of cancer that killed my father, which will save them some cash over the years I would have otherwise spent on heightened screening.

Should I include these things in my appeal letter? What type of information are they looking for to help them sway their decision? Is it even possible to win this sort of fight or am I just putting off the inevitable? Any tips welcome.
posted by something something to Work & Money (12 answers total) 2 users marked this as a favorite
Have you called yet on the phone? Often you do not need to send a letter or get the doctor's office involved or anything else. I've had claims for expensive tests denied many times and sometimes all you have to do is call and ask for someone to look again and reconsider.
posted by telegraph at 3:15 PM on April 6, 2015

Best answer: Was the doctor's office supposed to have the test pre-certified? Seems odd to me they'd perform a $6k test without securing authorization or payment in advance. Did they discuss with you in detail who would be financially responsible if your insurance didn't pay? Don't let them push the cost on you. They have to fight with the insurance company, and they should eat it if they can't win. This advice is slightly more difficult if an outside lab performed the test.
posted by ThePinkSuperhero at 3:20 PM on April 6, 2015 [2 favorites]

To properly address the issue, you're going to need to know why the analysis was denied. Was it the lab (insurance may be contracted with a different lab than one your provider used). Was it the specific testing ran -insurance may only pay for certain genes that it considers medically actionable. Is it documentation-some insurance companies have refused to pay for cancer testing unless a genetic counselor is involved to verify appropriate orders as there is such a high chance for misorder, even of a known familial change. Was it timeliness-preauth may be needed PRIOR to testing and may only be given afterwards in X circumstances.

All in all, agreeing with telegraph for you or your provider to call the company directly.
posted by beaning at 3:21 PM on April 6, 2015 [1 favorite]

Response by poster: Clarifications: Only one lab in the country performs this test, Myriad Genetic Laboratories in Utah. There is actually some controversy about them holding patents for these genes and charging quite a lot of money for the tests. My doctor's office told me the lab would call if the cost to me would be greater than $350. No one called.

The claim was denied because "genetic cancer susceptibility panels using next generation sequencing are considered investigational for all applications...[Insurance Company] found insufficient evidence in peer-reviewed medical literature to show a beneficial effect on health outcomes. [Insurance Company] does not provide coverage for investigational services."
posted by something something at 3:25 PM on April 6, 2015

As a data point, I had a rejection for a precertification on these grounds and there seemed to be nothing that could make them budge. According to them, the next step was to appeal to the state's insurance board (IL). Which we did, and they said we couldn't appeal because my employers plan was "self-insured" which I guess means that allows the ins co to really call all the shots. The doctor at the time advised that lawyers were the next step but then I got a new job and it was moot.

The doctor's office should work this out with them. Presumably they assumed it would be covered so they must have some experience with billing for it.
posted by bleep at 3:40 PM on April 6, 2015

I worked in insurance for over five years. (I did not work with the kind of insurance you have.)

Where I worked, which was a company with an extremely good reputation, anything sufficiently uncommon that was not routinely seen could be denied in error because the sometimes entry level person handling it wasn't familiar with the in-and-outs of (weird, obscure thing). Sometimes, if you just called customer service and asked a few questions, they would shoot a priority message to the claims department and it would get reviewed a second time.

The insurance industry is insanely drowning in information. Every state has its own peculiar exceptions and the claims people are all suffering information overload much of the time (while trying to make quota, so there just isn't enough time in the day to research everything they really should be researching). The company I worked for reinvented internal search about every two to three years to try to deal with that fact. It was an on-going battle.

So I will suggest that your first step be to just call and act all puzzled, like "My doctor's office seemed confident that this would be covered because it saves so much money down the line on x, y and z and it was ordered on grounds of medical necessity. They were so confident, I just assumed they had experience with billing for this and I am simply shocked that it was denied. Can you please take a quick look at this and see if it looks to you like this denial is a mistake?"

The letter you got is probably a form letter. You pull it up in the system and fill in the blanks. The legal department approves all language used in form letters so as to make sure it is defensible in a court of law if they get sued. Please don't be overly impressed by how fancy the language sounds. Just call and be all wide eyed innocent and sure this must be a mistake.

If they tell you, nope, it's not covered, then go get with your doctor and get a letter of medical necessity etc. But you may not need to do any of that. You may be able to get this resolved by just calling them.

Be very polite. The people in the call center get cussed out daily. So being grumpy as hell won't help you at all. They've heard it all before. But being the one customer who was a delight to speak with that day may get you better service. It may help them go the extra mile on your behalf.
posted by Michele in California at 4:01 PM on April 6, 2015 [3 favorites]

Only one lab in the country performs this test, Myriad Genetic Laboratories in Utah.

AmbryGen and GeneDx also offer BRCA1 and BRCA2 tests. The Supreme Court struck down Myriad's gene patents, and Myriad has settled or lost subsequent lawsuits against other people offering BRCA1 and BRCA2 tests.

The claim was denied because "genetic cancer susceptibility panels using next generation sequencing are considered investigational for all applications...[Insurance Company] found insufficient evidence in peer-reviewed medical literature to show a beneficial effect on health outcomes. [Insurance Company] does not provide coverage for investigational services."

This may be their way of stating a position that the physician should have used a more focused (and cheaper) test. What is the Current Procedural Terminology (CPT) code for the test?
posted by grouse at 4:07 PM on April 6, 2015 [3 favorites]

Best answer: It's possible that the issue is not that you had a test for BRCA mutations when you had breast cancer, but that you had a panel looking at other mutations for potential other cancers. Even if the test for the BRCA mutations were the same price as the full panel, sometimes insurance companies can be weird about that. It's also possible that your doctor's office didn't code correctly to indicate that you had a family history of other potentially heritable cancers that made testing for colon cancer-related mutations reasonable. I would speak with the insurance company, find out what the issue is, and see if you can get your doctor's office to resubmit codes that reflect the rationale for the wider panel.

If going through your insurance and your doctor's office doesn't get you anywhere, it might be worthwhile to talk to Myriad and see if they will reduce the price for you. I am 100% sure that the insurance companies are not paying them 6K for that test, so if you do end up being responsible for it, there is a good chance that they will work with you on the cost.
posted by The Elusive Architeuthis at 4:12 PM on April 6, 2015

I had that test done last year, through Gene Dx. (I'm negative for the mutations, yay!) My insurance company, Kaiser, found it persuasive that my mother and sister, and my mother's sister, and their mother's sister, had all had breast or ovarian cancer, but mostly that my sister had had the test, and was positive for a BRCA1 mutation. I had to get my sister's medical records, to prove that.
posted by pH Indicating Socks at 5:34 PM on April 6, 2015

Best answer: Given the cost, I'm guessing you had the Myriad myRisk panel, which is significantly more expensive. When my wife and I spoke to a genetic counsellor/oncologist about testing last summer, as I recall the oncologist said that the myRisk panel was primarily investigational, and there wasn't evidence to support any changes in treatment based on the outcome of the additional gene panel. Based on that, we chose a BRCA1/BRCA2 test from a different provider which cost ~$1600 and insurance got a discount of $1250 off that. (total cost to insurance company $330, we would have paid 10% deductible = $33 but had already exceeded our out-of-pocket max)

If you had the myRisk panel, and your doctor didn't give you other options, I'd have a discussion with them about why they didn't provide options and what they'll do to fix that for you. They should have known that the myRisk panel was significantly more expensive than other options. You can also talk to Myriad about them discounting the test since it isn't covered by insurance.
posted by dttocs at 5:39 PM on April 6, 2015 [3 favorites]

They should provide you the criteria they use in determining whether or not to cover genetic tests. I was charged similarly for a genetic mutations test and I had to hunt for this info myself by contacting my insurance and asking where it was stated that this test wouldn't be covered because I was unaware of that. I would think the fact that you have breast cancer would make you qualify if this is something at all related to that. I had Aetna, for what it's worth, and I don't remember how it got resolved -- I think I spoke with the lab and complained to get them to lower the amount and I paid off the rest.

In a nutshell, I covered all my bases and talked with my doctor, the lab and my insurance company about it -- my doctor for the justification that I needed the test, and the lab/insurance trying to get them to reduce it due to financial burden. I think you'll have to do that here. It's bullshit the lab said they would notify you if it was over a certain amount and then didn't. I just found my old question, which may have some helpful responses for you -- the bill was apparently $1300 and I definitely did not end up paying that much.

I would definitely include all the info you think is necessary, and provide documentation as much as possible. Medical records, and any opinions from doctors will be hard to argue. It might also be worth knowing what exceptions there are generally -- like a doctor can send bloodwork to an out-of-network lab if they believe it's necessary to ensure quality.
posted by AppleTurnover at 8:05 PM on April 6, 2015

Response by poster: Updating on this crazy situation in case anyone else has this issue going forward: Apparently it is practice for Myriad to bill the insurance company $6000+ and, if they don't pay, write off the vast majority and bill the patient $375. They are first going to file an appeal on my behalf, though. This seems to be sort of a weird way to run a business but as long as I'm only on the hook for a few hundred bucks I guess it's fine with me.
posted by something something at 12:26 PM on April 7, 2015

« Older Asking for a book.   |   In search of the perfect socks Newer »
This thread is closed to new comments.