Health Insurance - Mammogram and Deductible

[Cypress]

My insurance plan has a $500 deductible.

I have a benign growth (calcium deposits) in my right breast that the Dr. requested needs a closer look in mammography. The billing is coded as diagnostic and I end up getting a majority of the bill. It is not billed as an annual mammogram.

Last year, I successfully argued that this is a covered service, medically necessary, a mammogram and the cost should not be passed on to me. That decision was in my favor. This year, the grievance was denied. Same insurance company. They sent a copy of last year's grievance and said they would only do this one time as a courtesy to me.

Can I take this complaint somewhere else? The denial of coverage gave a place to appeal, but I am reluctant to follow the insurance company recommendation. They do not want to pay. I don’t want to pay. But, have sent $25 in towards a gross amount of $350.00.

[SiouzQ.]

I am in the exact same situation as you are - my plan allows for one screening mammogram per year, in which the radiologist requested that I come in for another more detailed view (same diagnosis-calcifications). I have to pay for the second mammogram, which goes toward my very high deductible (set up to pay $55/month for a year) but I have to go back in October for yet another diagnostic mammogram to see if there are any changes. Sure is a lot of x-raying in one year, let alone another $500 or so dollars. By then I will have hit my deductible and the plan will pay 80%. I have a lot of medical stuff to pay for this year, sigh...

[redfox]

Get the doc on your side, and have him advocate for coverage.

[Cypress]

I have to comment, as this is a woman's major health concern, is there unfairness at work, or insurance simply not wanting to pay for necessary coverage toward the well being of their client. A screening will avoid more complex expensive testing and procedures if a problem is found early! Preventative medicine is better and cost efficient. I imagine more than one person in this situation walked away as costs escalate and it's really a matter of what you can afford. I realize it can be your life, but risk is a matter of insurance not your life. This seems so unfair.

My DR did support me last year in this. I have a physical scheduled for October and will certainly present this again.