CT Scan Denied

Hubby123

New Member
3
Hi, my wife was recently diagnosed with Kidney Cancer. As is often the case the initial catch was some other CT scan (in this case Cardiac) which spotted something on her kidney.

Hospital immediately ordered a kidney specific CT scan (which was denied) and a follow up MRI which seems to have gone through. In talking to the hospital (very reputable hospital) it sounds like they requested pre-auth of the CT scan in question which was denied, but they elected to perform the CT scan regardless, based on medical necessity.

We were not told of the denial when we went in for the CT Scan. We got home from vacation to find the denial of coverage letter from the insurer. Needless to say, not the most welcome news at an already stressful time. It sounds like the hospital is already disputing the denial and is following up with the insurer w/o our prompting, so at least we have that going for us (although it does look like both sides have outsourced the dispute to 3rd parties, which is not great).

The letter from the insurer indicated we had the right to request full records relating to this denial, which I am doing for my own review and records.

Question is, do we have any recourse here if the hospital never told us about the pre-auth denial? While I am not sure we would have said "don't do the CT scan", we might have at least duked it out with the insurance company up front a bit. While a CT scan is not a HUGE bill, it would nevertheless be an expense we've not budgeted for, and it seems outlandish that we should have to pay out of pocket for something to help prove a cancer diagnosis, whether it was conclusive or not. At the moment I have the urge to call up the insurer and scream "Are you really telling me that you think your 3rd party flunkies who evaluated the medical necessity of this CT Scan are smarter than the doctors at [insert name of world renowned cancer center] ?!?!?!" and also to call up the hospital and say "Why the hell did you not tell us up front the insurer denied coverage?!?!"

Thanks
 
Sorry, not sure if I was not supposed to name names. Insurer is UHC. They seem to use a company called "evicore" to make these determinations.
 
If something else was found during a test, and it is not related to immediate pain/medical problem, a pre-authorization would be in their right to require. (Unless the kidney was related to her current symptoms). If the hospital felt that time was the issue, have them fight it for you to overcome pre-auth. If they are not successful, then tell the hospital to give you the lowest cash negotiated rate.
 
First, I am sorry to hear about your wife’s condition. All my best for a quick and full recovery. And, This may not be the best forum to find a conclusive answer because there is so many variables, so please keep this in mind as you progress through the answers.

My initial reaction is that pre-authorization for this CT scan is your responsibility, not the hospital/doctor, and that if true, this may be the reason it was denied. You should appeal, good chance it will be over turned. You should also review your Summary Plan Document (SPD) as a start, because you need to find out who is responsible for pre-auth. The records may also help.

Let’s assume you were responsible for the pre-auth (which is what I believe so far) then the hospital was wrong to request it, and they compounded the mistake by not telling you about the denial.

While I understand your frustration with the UHC staff and your desire to scream, you may want to hold off until your learn the facts. Keep us posted.
 
State insurance departments have policyholder services divisions and yours might be of help. When a relative almost lost his fingers in a skill saw accident, the hospital had him life-flighted to a hospital 200 miles away where his fingers were successfully reattached. The insurer denied the $25K helicopter flight even though all of the physicians involved, including perhaps the top microsurgeon in the world, swore that this was medically necessary. The director of the Life & Health division of the state insurance department wrote a letter to the insurer and the claim was promptly paid.
 
I tend to agree with leevena on this.

You were not told of the pre-authorization. It is most likely your responsibility, or at least in conjunction with the attending, to to request the pre-authorization.

Invoking "medical necessity" seems to say there were no symptoms, nothing to warrant the additional CT.

Cardiac scan OK and pre-authorized.

Kidney scan not authorized, may or may not be necessary at least at this point.

This may seem counterintuitive to you at this point but if carriers paid every claim that came in the door your premiums would truly be unaffordable.

Good luck.
 
I just read this today because I came home after also being "denied" coverage by United Health Care, for the CT scan of an aneurysm behind my knee. The aneurysm is very painful, and has been seen by untrasound, and there is a physical buldge and contant black bruise, which speads when I am active. I cannot fly on a plane and it limits my mobility. Just when I thought treatment was around the corner, UHC does not feel it is necessary to have the CT scan. My doctor needs the scan to decide on the best treatment option (and to see it clearly!). So I did not get the scan, and I am holding back tears. Is this just United Health Care, or do they all refuse?
 
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