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I am just curious if anyone else's doctor ordered a baseline mammogram for them at age 35. I had one last month, but my insurance is denying payment due to me being under age 40, which is the age that regular mammograms typically start. When I called my insurance, they said that my husband's employer (who we are insured thru) specifically wrote into the contract that they did not want the baseline mammogram covered. I started looking stuff up online and it seems like the recommendation is a baseline between ages 35-39 before the br___t tissue becomes dense from natural aging, and then regular mammograms starting at age 40. Most of my friends have had their baseline at 35, so I am totally shocked that my insurance denied this claim. If I want to file a grievance, which my docs office said they would support and supply me any letters or paperwork needed, I actually need to file the grievance with my husbands employer. In hindsight I probably should have checked into this before I had the mammogram, but my doc is in the network so I just assumed it was OK. Even now that I will have to pay out of pocket, I think I probably still would have done it because it makes sense to do. Geez, it's like they (insurance, employers) would rather pay for you to have a mastectomy and chemotherapy than pay for a stupid baseline mammogram, you know? I am just wondering what anyone else's experience has been.
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Wow! I didn't know any companies wrote their insurance like that. Ours covers any prevent_tive testing when ever deemed necessary by your PCP. I had a MAM and a b___st U/S at 16, 18, 25 and I will have another this year at 30. I have VERY fibrocystic b___st tissue and a family history of b___st cancer. Did the doctor have (or could find) a reason to call it medically necessary - lump, family history, pain in b___st? If it was for diagnostic purposes instead of prevent_tive, I believe they cannot deny it.
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Well, I guess it would be considered preventative because they want a healthy mammogram (hence the term baseline I guess) to be able to compare future films against when you get older. My doc's office was really p__sed off about the whole thing because they think that insurance is discouraging women from getting the recommended care. You know after all of these posts about everyone being young moms, I was certain nobody here was going to be able to talk about a baseline mammogram at 35. LOL!
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I haven't had this happen but I know how frustrating insurance can be. I was seeing a fert_tily Dr. to get pregnant with Mason and had numerous preg. test to check levels. I was not aware that they sent them to a lab not covered by my insurance (ONLY because it was a faster turn around). So I was stuck paying $200.00 out of pocket for pregnancy tests. I fought with the Dr. office for months but they wouldn't budge and the insurance wouldn't pay them. Sucks.
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I agree that there is a major flaw in the system and I would probably spread the word at hubby's workplace about it, and write your congressman about it. I also agree it does discourage women from being proactive. Having worked in insurance for years, I would go to the matresses to get reimbursed for the mammagram (couple hundred bucks, right?) If you keep bothering them and asking each person that gives you lip to speak to their supervisor, you just may get it paid. Did anything show up on the mammagram (like a cyst) so they could re-code it as diagnostic?
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Also, wanted to say I thought you did the right thing regardless of inusrance paying for it. I think it's a great idea. I have had two mamograms for lumps and I am glad I have those to refer back to if ever needed. I had never thought of that before but it's a great idea. I wonder if your Dr. would/could change the need for the mamogram to medically necessary??? Like Kara H. said I think they would have to pay for it then. I think it's crummy that you have to file the complaint with your dh's company. Slight conflict of interest if you ask me. Keep us updated.
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Per example on how coding makes a difference: A coworker of mine (exact same insurance coverage) has a short lutal phase just like I do and was trying to get pregnant. Her doctor had the secretary do a pre-auth with the insurance company for Prometrium. They said that they don't cover anything fertility related. Her doctor went ahead and wrote the script to see if they could get it to squeek thru at the pharmacy - but it wouldn't go. My doctor wrote the script without doing a pre-auth and the insurance company a__sumed it was for medical reasons like premenopause or inducing a period on a non-ovulatory cycle and covered the script (which was really expensive -$140 per month!)
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My mammogram was totally clear so I am not sure if they can twist it to be diagnostic. I'll let you ladies know what happens.
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I agree with Kara it’s hard to see such companies who wrote their insurance like that. You certainly did the right thing regardless of waiting insurance paying for it. Mammogram is helpful in determining breast cancer early. It is an X-ray test which creates inner breast tissue’s images on film. This technique known as mammography held through the help of devices supplied by ilexmedical.com and other. It identifies cysts, calcifications and tumors present in the breast. Very essential to detect cancer in a curable stage, however there are other tests also required to confirm its accuracy.
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