Connect
MR Guided SBRT and insurance?
Has any had issues getting mri guided sbrt approval through insurance? I was scheduled for the initial trial run this Monday at UVA. The hospital had to cancel it due to waiting on prior authorization. The insurance company has declined it an I think the next step is a peer review. Does anyone have any insights?
Like
Helpful
HugInterested in more discussions like this? Go to the Prostate Cancer Support Group.
Connect
Was SBRT approved without MRI? I do not think there is a separate CPT code for MRI guidance. Should be the same as CT guided.
The insurance said that the mri guided wasn't medically necessary. They would approve the ct guided
Have you already had an MRI?
Did the insurance approve that?
What type insurance do you have?
@brianjarvis I had an MRI that prompted the latest biopsy. I have blue cross blue shield and that mri was approved
@rclev1 It will then take an appeal by your physician as to why an MRI-guided fusion biopsy is medically-preferable to CT-guided. Your physician should know the medical language to use to get it approved.
-
Like -
Helpful -
Hug
1 Reaction@rclev1 Have you got the codes the provider wanted approved? If listed below you have a chance of approval with an appeal. Problem is that delays treatment by 3-4 months since external appeal (2nd level) usually required. If just the first 6 on the list were used it should have been approved. VA BCBS is part of Anthem which owns Carelon that sets almost all policy guidelines. Anthem pays $0 if "Not Medically Necessary" so you need to decide to go with an approved treatment or fight the insurance and take the treatment delays. Anthem wins either way, and it would likely be the same with the other commercial insurers including Medicare Advantage plans.
From Carelon Radiation Oncology Prostate Cancer SBRT
77295 3-dimensional radiotherapy plan,
77301 Intensity modulated radiation therapy plan,
77338 Multi-leaf collimator (MLC) device(s) for intensity
77370 Special medical radiation physics consultation
77373 Stereotactic body radiation therapy, treatment
77435 Stereotactic body radiation therapy, treatment management
77470 Special treatment procedure
G0339 Image guided robotic linear accelerator-based stereotactic radiosurgery
G0340 Image guided robotic linear accelerator-based stereotactic radiosurgery