Editor's note: If you have questions about the practices of your managed-care coverage, ask the experts at the Department of Managed Health Care. They take up issues ranging from difficulties getting an appointment to denial of a doctor's recommendation for treatment.
I am a breast cancer survivor, and, in order to ensure that I stay healthy, my doctors recommended that I alternate between having a mammogram and an MRI every six months as a follow-up to my treatment.
My health plan disagrees. I had an MRI a few months ago that it refuses to cover because they say that an MRI is considered experimental in my case and does not follow their medical criteria. I would like for my health plan to pay for my MRI.
– Mary Ann Jung, Davis
Because most people have heard about magnetic resonance imaging, or MRI, it may sound strange that a health plan would deny coverage and call it "experimental" or "investigational."
How can it be experimental when people seem to be having MRIs all the time, and it is known to be a relatively safe diagnostic tool?
Even common procedures like an MRI, or popular medications like Botox, can be denied as experimental or investigational when they are used to treat or diagnose a condition that could be treated either more effectively or more safely by a more commonly accepted method.
For example, most people know that a Botox injection can help reduce the appearance of wrinkles. But what about using it to treat a migraine? A doctor could prescribe Botox, only to have the health plan deny it as experimental because other medications are considered safer or more effective.
Although an MRI can be used to detect abnormal tissue in breast cancer survivors, is it safer or more effective than diagnostic methods such as mammograms or ultrasounds?
To find out, the DMHC sent your complaint through the independent medical review process and asked a panel of three doctors to decide.
The panel ruled that an MRI was not likely to be more beneficial than other available therapies. So, the DMHC upheld your health plan's decision.
We want to stress, though, that every patient's situation is unique. Consequently, this decision does not affect all breast cancer survivors seeking coverage of MRIs.
If a doctor prescribes an MRI, or any other treatment for that matter, contact your health plan to ascertain whether that the treatment will be covered before proceeding.
And remember, if a second opinion is needed, the DMHC's independent review process might be the answer.
To ask a question of the Department of Managed Health Care, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
