Any experience dealing with eviCore? Medical procedure denied!

Those s o b ‘s got into my insurance company who now uses them for decision making. Luckily I had 2 MRI’s approved by them in a letter not my insurance company. Evercore is owned by another company so there are a lot of shareholders to keep happy
It’s like having a dis advantage plan.
They have denied people who needed lifesaving treatments. They say they are there representing the best and cheapest options. That’s bs to me. I hope my insurance company that I’ve had for over 10 years without paying for anything but my SS Medicare and my States Medicaid. My State has the best insurance in the country and we are all blue. Nobody is red. Even the mailman. Republicans try to get in but there is no support here for republicans. By the way UHC sucked when I made my choice to a 0 premium plan

Sorry to say, BCBS is no better, they also use evicore. They deny authorization for mris or any other radiology testing that my doctor has requested. So how are we supposed to find out what is causing my ongoing leg, hip and back pain issues? Does evicore think they know what is better for me than my doctor? So what, are we just supposed to suffer or worse? Something should be done about this. What do we pay monthly premiums for ? Pay your $35.00 copay to see a specialist who prescribes tests and then they get denied by evicore.

I was just informed by my doctor that my mri autorization was denied because I have to have 6 weeks of therapy at $35.00 a crack and then it will have to be resubmitted. So, I have to pay at least $420.00 out of pocket for 6 weeks of therapy and then maybe they will authorize it. Also my pain gets much worse with any kind of strengthening excercises. What a crock. They also told me that BCBS Advantage is about the worst insurance to deal with. I think that each different insurance company sets the standards that evicore follows. They should change the name to Nevercore... I will be looking elsewhere for insurance in December.

Evicore is a third party that insurance companies hire to do prior authorizations, so you’re right and Evicore follows their guidelines.

I am a caregiver for my father and have learned very quickly that traditional Medicare with a supplement is known as the better way to go because traditional Medicare doesn’t put up those same roadblocks.

I don’t want to sound like I’m finger-waving. Please know that the same thing happened, sort of, to us. I put my dad in BCBSIL Medicare Advantage Flex, which we actually haven’t had any problems with, and it’s less expensive than the previous traditional Medicare + Supplement he was on. But his doctors keep telling us that it’s like playing roulette because you don’t know what they will approve.

Personally, I think (as someone who’s not on Medicare), I think it’s stupid how confusing it is, and how much more expensive it is to stay on traditional Medicare because of the prescription drug and other benefits that are like “add-ons.” If there was some way that it could be accounted for, then I wouldn’t have even bothered to compare prices with Advantage plans. On the traditional plan, we were paying double per month what we pay now and paying more out of pocket for medication.

With his current plan, we pay a fraction and like I said, we haven’t had problems. But I still want to change him off it next year because the worry I have that something won’t be covered is too much. In our area, BCBS has the best coverage.

This is a known issue: https://www.nytimes.com/2024/05/25/science/medicare-seniors-authorization.html

Well, that's very discouraging to hear about BCBS using eviCore as well. Insurance is a very seedy business. They're more than willing to take our money, but when we need expensive tests done, they find any excuse to block the procedure. Gotta make sure those senior VPs and CEOs can afford their million dollar homes and yachts.

Amazingly though, my wife got no push back on getting an MRI done recently when she twisted her ankle so badly she ended up with a hairline fracture (the xrays showed that). But they wanted to make sure no ligaments or tendons were damaged, so they are doing the MRI as well. We use United Healthcare through my wife's insurance that she gets from the government (known as GEHA). I still don't quite understand that relationship.

I'm only a few years away from Medicare and don't look forward to that.

The only thing I can say about getting to Medicare is that you need to understand the difference between the Medicare Advantage Plans, Medigap Plans, "wraparound" plans where you retain your employer's coverage after retirement and Medicare becomes primary, the insurer becomes the administrator.
I cannot repeat often enough "there is no free ride" - an Advantage Plan with a tiny, or no, premium, will definitely not offer as much as a Medigap plan, will have more restrictions, a preferred provider setup, and higher copays.. And usually, if you qualify, a wraparound where you keep your original insurance carrier tends to be best.

Sit down and do some future math. Try to look ahead 15-20 years - what afflicted your parents and older siblings may well come your way. Don't be swayed by shiny perks like "Silver Sneakers" - if they're in your "best fit" plan fine, but if you can't afford your meds, a gym membership is no good to you.
When I became Medicare eligible, it was clear that with a few health issues, we were going to continue to have rising health costs as we age. And an abundance of PT to keep my body moving would be needed.
So low copays were important - in good years we view the higher premium as a "down payment" on future needs. In bad years, we breathe a sigh of relief that we didn't have to dip into savings to cover medical bills.
We also planned to (and do) travel extensively, so we needed portable care - driving 1500 miles to get a lung infection treated is not an ideal situation.
Prescription copays and the most general possible formulary are important too. The meds you need at 80 are often much different than at 65.

Medicare may be the single greatest reason why the life expectancy of our WWII and Boomer generations rose so rapidly. My grandparents and their siblings only had the GP, who listened to their lungs, prescribed penicillin, and got $5 a visit.

@andytheman and everyone else who has weighed in here, while we all wish there were endless health care dollars, "managed care" aka third-party pre-authorization, IS EVERYWHERE, It's Everywhere, it's everywhere.
You can call them UNUM, eviCore, Medicare Medication Manager...

Costs escalate... hospitals and clinics build fancy new buildings with high-tech equipment, concierge services, waterfall walls and fancy artwork...new high-priced tests come into everyday use... new drugs can cost thousands of dollars per dose... wary doctors order possibly unnecessary tests to avoid malpractice suits ... or because their patients demand what they saw on TV, what their friend says, or what Dr Google diagnoses.

So, let's assume the insurance company said an automatic "yes" to every drug request -
Initial diagnosis of high cholesterol? Maybe an older generic medication like lovastatin (30 tab 10mg under $20), with a long history of safety and usefulness would work as well as Repatha? (2 injections $600) Sure a small percentage may need the pricy drug, but there is a "ladder" of options on the way to the high price. One year's worth of Repatha injections is almost as much as I pay for my entire Medicare wraparound insurance premium, and it's not the only service I require.
Examples like this abound.

When it comes to diagnostic tests, the water is more murky. Good doctors are already following best-practice protocols, and shouldn't be second-guessed by bean counters. But there is no standard and accepted best-practice protocol for many situations, the doctor and your insurance company may rely on two separate lists, and the situation gets sticky.
Diagnostic and billing codes also add a complicated dimension. The physician who gives his reason as "rule out xyz" will have different result then the one who writes xray inconclusive, PT ineffective, suspect XYZ"
My doctors requests for exceptions have been accepted without more than a phone call on heart tests, gall bladder diagnostics, and extended PT.

We need a better way to do this, but unless we want insurance premiums to by 4-5 times what they are, some controls are necessary.
Let's keep this issue front and center with our government - "insurance for all" is no good if nobody can afford it!

Yep. Heart scans with high calcium scores are not considered diagnostic for a heart condition. Plenty of people, including me, have high calcium scores but do not have a heart condition. You need to declare you have symptoms like chest pain, shortness of breath, arrhythmias, etc. to have a stress test and an echo covered by insurance companies.

Ask your cardiologist about this. They will know how to deal with EviCore. They have to deal with this type of issue on a daily basis.

I am one of those lucky folks on Medicare who has excellent supplemental insurance. I also have Vietnam Veteran limited disabilty coverage through the VA. Volunteer Sue's explanation of insurance coverage was excellent!

I use Neighborhood Health Integrity. I’ve had them for 10 years and they have contracts with Medicare and Medicaid so I’m a dual insured. Medicare pays 80% and my state’s Medicaid pays 20%. I also have a free part D for prescriptions.
My monthly premium is $174.00 a month and it goes up every year but only by $10.00 on average. My membership card has printed “member can not be charged copays” “member can not be charged deductibles”
So my prescriptions cost nothing.

Evercore came into play when I received a letter approving my ENT for several MRI’s and 2 cat scans and 3 X rays from my other doctor (my pulmonologist)Both doctors were approved and all radiologist procedures were approved. Along with a speech therapist because I have a paralyzed right vocal cord. I had my esophagus dilated because it had become too narrow for food and liquids to get into my stomach. There is a danger of having stomach contents being aspirated into my lungs which causes pneumonia and possible death.
Evercore approved my cardiologist sonogram and echocardiogram for a torn aneurysm in my aortic artery.
They approved my ENT and 2 surgeries because the first one was botched by my gastroenterologist ( he missed an ulcer and corrosion in my first surgery. I had to spend 3 days inpatient to straighten out my ulcer. My photonic, medication to break up my ulcer and corrosion. All 100% paid for by Evicore. So even though it appears that my health insurance is now using Evicore.
They had all of these procedures and both surgeries approved by Neighborhood’s use of Evicore.
Now my dental was covered by Medicaid and it still is but they sent me a Delta Dental Card.
Both get together to pay for my dental care. I don’t remember who goes first but that doesn’t matter.
Evicore has been good for me.
I have more surgery including possibly a tracheotomy and stenting it.

I spent a month on United Health Dual coverage and I hated it. It’s gotten too big.
I went back to Neighborhood.
United had argued with me that my dentist was out of network and I had to pay out of pocket.
I looked up my benefits policy and there she was. In Network!
To get all this good healthcare you have to be 65 or less if you have a disability like I do. You have to be earning less than the country’s maximum regarding the poverty rate. Meeting these criteria made be qualified for everything. I don’t like Medicare for all like Bernie Sanders is proposing I believe that the richest country in the world should have free or reduced healthcare. Without raising taxes on regular middle class income and take it from a new wealth tax. Sorry this is so long but I don’t think Evicore is that bad