Consumer Alert: Breast cancer patient battles insurer for expensive test

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ROCHESTER, N.Y. – A Brockport grandmother reached out to News10NBC’s Deanna Dewberry when she was having trouble getting her insurance to approve an expensive scan.  She was just diagnosed with breast cancer, and there are few things scarier than the initial days following a cancer diagnosis. That process is made more stressful when you’re waiting for insurance approval, and this patient has been waiting for more than two weeks.

It was a routine mammogram, at least she thought it would be.  But this year, for Karen Heaney, it was anything but routine.

“So, the doctor was questioning it, and they did the biopsy, and it came back positive stage one,” said Heaney.

Fortunately, doctors caught her breast cancer early. That’s the good news. Her doctor said she needed another scan before moving forward with treatment.

“He called me, explained everything, and suggested that we have an MRI to make sure that there wasn’t something else hiding or that they might have missed, said Heaney.

She’s talking about a breast MRI, an expensive test that according to the National Institutes of Health is three times the cost of a mammogram.  But for more than two weeks, she’s been waiting for approval from her insurer.

“I’m really angry,” said Heaney.  To me, this should not even be a question. If a medical doctor and a renowned clinic say here’s the diagnosis, next stop MRI, it should be no problem.”

But it’s not that easy.  Heaney says when she called her insurer, Excellus Blue Cross Blue Shield, she was told her test must be approved by a review board. Joy Auch, a spokesman for the insurer told me, “Specially trained doctors and other health care professionals review the medical documentation submitted by the provider and evaluate the request based on evidence-based criteria and standard guidelines.”

And as Dr. Lori Medeiros, Executive Director of Breast Services for Rochester Regional Health explains, breast MRI, while effective, is controversial.

“One of the problems when we started using MRI is it did increase the rate of mastectomy nationwide,” Dr. Medeiros explained.

Part of the reason for that increase is because a breast MRI is a very sensitive scan that picks up everything that looks abnormal, even tiny benign legions. And studies show that following a breast MRI, patients were more likely to request mastectomy because of the fear caused by benign findings on the MRI.  But doctors insist Breast MRI is diagnostically helpful.

“The reason we do the MRI after the diagnosis of breast cancer is to see if there are other areas of tissue that could be involved, said Dr. Medeiros.

Heaney questioned whether the cost of the test was guiding the insurer’s decisions about her care.  But Auch insists “The goal is to ensure that the services are medically appropriate and are proven to help with the patient’s medical evaluation, diagnosis, consultation and or treatment.  Breast MRIs are considered medically necessary when certain clinical criteria are met. About 95% of all prior authorizations are approved.”

Two days after I reached out to the insurer, Excellus approved Heaney’s scan. When faced with insurance questions, it’s important that like Heaney, you become your own advocate and call your insurer yourself.