I need help with a medical procedure insurance denial that is necessary?

I had an MRI a couple weeks ago, which showed a syrinx in my spinal cord (also known as syringomyelia). The MRI was for brain/neck only and was done because I was having headaches. I need to have an MRI on my entire spine to rule out more syrinx formation. Syringomyelia is very serious and can cause paralysis and/or death if not treated. My dr. has attempted twice to get approval for another MRI. She got the neck and brain approved to be done again with contrast to rule out other pathology but twice they have denied doing the whole spine. Is there anything I can do to fight this and get the further MRI testing since its medically necessary? Also, it takes a highly trained specialist to deal with syringomyelia because it is so rare. None of these specialists are in my state (only drs. in my state accept my insurance). Is there a way to get them to pay for me to go to another specialist? I had a conversation w/my ins. co. this morning and they say "no" since there ARE neurologists here.
Additional Details
Also, I forgot to add that if I have syrinx in my neck area, it is very possibly, even likely I could have it further down my spinal cord.

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Ask for your medical records too. Write an appeal letter. Complaint form to the Insurance/Medical with the State appeal. Look in your government yellow page and your book you receive, call them they are suppose to give you this information.

If you have an insurance agent, get them involved right away. You're paying for their services. They know the lingo and often have contacts within the carrier to find the person who can say "yes." (Anyone can find the people who can say "no."

The fact your doctor is supporting you is a good thing. Each insurance company has a Chief Medical Officer. I suggest you check out their web site and send that individual a certified letter. Include the fact that your doctor deems the procedure necessary. Send a copy of the letter to the president of your health plan. Most carriers have a staff of folks who deal with letters to the president or CEO of a company.

Sorry you're having such problems. Hang in there.

you should call your ins. co & ask who you need to see since it sounds like the physician you are seeing is out of network. the ins co should be able to provide a list of which neurologists / neurosurgeons within your network. dont be fooled by thinking you are going to the "best" specialist, etc. i work for an ins co & many consumers are grossly misinformed about their own dr. - Many do not even check the drs history, such as the medical board for disciplanary actions, education, publications and board certifications. it is found that if another person brags on that dr as "the best" then it is taken as face value. some of the best physicians you will find are at teaching hospitals. it sounds as if your 2nd MRI may be able to be covered provided you go to a specialist in your network. The services you receive out of network may be covered if you are on a PPO, it just may apply to an out of network deductible (which you are liable for) an HMO though you will probably be fully responsible for if you go out of network. Also keep in mind, physicians that CHOOSE not to be in a network may not be eligible due to disciplanary actions taken against them. PPO and HMOs will rarely allow a physicians or hospital to remain in their network that has actions against him. good luck.

You said you had an MRI on your spine a couple weeks ago... So, they're probably wondering why you need another one. Were the films unclear? without contrast? Why the repeat? If it is necessary, find out what you need to do to prove its necessary? Like, do they want you to have a second opinion? Do they want the results from one of the other mris? do they want your doc's ofc to send records? Find out, and do it.

If the doc's office said then want a repeat mri, for headaches, and did indicate the new/correct diagnosis, there may just me communication between the doctor's ofc & insurance...So, just ask. What would need to be done for this to be considered medically necessary.... good luck

Tell your physician to resubmit the claim with your signs and symptoms and they may pay. MRI's are very expensive and insurance companies have specific reasons why they will pay or NOT pay. They paid the first time because your sympton was a headache, not to rule out anything. Your physician should try resubmitting the claim with your signs and symptons as the major dx and they may pay. Insurance companies will not pay for MRI's for rule out's or preventative care. Also, if your doctor has received a prior approval, then make sure the prior approval number is on the claim. As far as your question about seeing a doctor in another state, if you are found to have this condition, then a neurologists in your network would have to refer you to a provider in another state citing that you need a specialist blah blah blah, and that you have this rare disease. The provider would also have to state in his letter to the insurance company the physicians name and speciality, but it CAN be done. Best Wishes!

A lot of the care you can get that is covered by your plan is determined by the plan that was purchased. You must be on an HMO plan. If it was a PPO plan, you can get care anywhere you want. It is just that the benefits are reduced (deductible is 2 or 3 times higher, and percentage paid after deductible is 20 to 30% lower) when you use a physician that is out of network. Ask your insurance company to get you a case manager assigned. This will be the person you will go through for all insurance questions and needs. Study your policy and make sure you understand the care you are entitled to. You may even want to have an attorney check it out for you. If it appears that you do not have coverage for the physicians and facilities you want, it will do no good to sue. You are already getting exactly what was promised in writing. But, you may be able to get some public assistance or something. Good luck, and God bless you.

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