MRI Denied By HMO

I have lower back pain which radiates down my left leg.  I have pain in my thigh, knee, and above the ankle. Driving my car is very painful.  I have had these symptoms for about 1 month and saw my doctor 2 weeks ago.  He suspects a herniated disc.  An exray was taken which showed degenerative changes.  Pre-authorization for an MRI was requested but my HMO said that it was not "medically necessary". What do I or my doctor have to do to convince the HMO that I need an MRI?

[broke123]

the doctors office is supposed to get the authorization for u. also sometimes, u need to be monitored by the doctor for about 6 months. when was the first time u went to see him? is he an ortho doctor?
it usually goes like this:
first visit: doc gets all ur complains, takes an xray n tells u what you might have, maybe gives u medicine.
second visit(maybe 2-4 weeks later): u come back sayin if meds helped u or not. if ur better or worse. if not better. he might recomend pt.
third visit (after 6 weeks): you come back sayin ur pain has not improved much, only for few days after physical therapy than it comes back. maybe now doctor tries an injection like cortizone.
fourth visit (month later): injection didnt help, your still in pain... now doctor can request an MRI. cuz he basically tried everythin and now needs to know in more detail what is wrong with your back.
at this point to get authorization shouldnt be too difficult. he can write a letter to HMO, sayin that uve been comin to him over a course of several months and nothing has helped. at that point they should approve it.

i hope any of this helps

[meikman]

I find more and more that Dr office post notes that patient is responible for obtaining pre-authorization for services.  If your Dr office tried to obtain one for you they may have used a wrong or not the right code.  For example if they told your ins co that you needed a MRI for leg pain then it'll be denied.

It is in your best interest to be pro-active with your ins co.  I would call and ask why the MRI was denied and depending on their answer you could act accordingly.  Say they said you just don't need a MRI for back pain you would tell them that it is much more than that tell them your symptoms then ask what you need to do to solve the problem.  More than likely they will say that a new request is needed along with the office notes.  Every time you talk with someone at your ins co it is recorded, not always on tape but the person whom you talk with will type the info under your file.

I used to work in medical insurance and know how hard it is to get help from some Dr office hopefully this isn't the case for you and the staff will be helpful.  One time after my husband had knee surgery we got a large bill.  After looking at everything I knew that the surgery was denied because it was coded as two separate surgeries.  I tried to tell the office staff the situation with no avail.  After two years of trying to get someone to look at the bill.  I would even tell them from the ins co what they needed to pay the bill no one would help. Finally someone decided to look at my husbands chart and low and behold the coded wrong.  We got a refund and even and apologize.  The staff even refused to let me talk to the Dr about the bill.

[MPV]

I'm not American so I'm not too sure. But I'm assuming your family physician should refer you to a specialist which will reccommend you need an MRI and if HMO refuses that any further problems that may occur in your back will be a legal issue against HMO.

Good luck.

[idesofmarch]

Make sure that your doctor gave the insurance company all of your symptoms and do whatever the doctor suggests while you wait for a YES answer.Sometimes there is a small list of "try this first" before an expensive test is allowed.  Sometimes doctors don't fill in all the answers needed or they word things wrong also.  Miscommunication also caused me a denial of disabillity time off with pay.  I found out that the doctor skipped some questions because he didn't think it pertained to his care of me.  Stupid I know!  I helped complete the form for my APPEAL and got the disabillity with pay.  I didn't even have him change his answers, I just made sure he filled out ever area this time.  College and doctors' degree and he didn't even know how to fill out a form! Good luck & it does sound like the doctor is correct in his diagnosis.