Any experience dealing with eviCore? Medical procedure denied!

Posted by hikerguy62 @hikerguy62, May 12 8:05pm

So, I had a calcium CT (a.k.a. coronary artery calcium or "CAC" or heart CT) scan done in March and it came back with a score of 2534. My right coronary artery alone had a score of 1639. If you're not familiar with this test, it's a modified CT scan that detects how much calcification there is in your coronary arteries. You want to see 0 of course. Anything above 400 means you have a very high chance that calcium is blocking your arteries. There's a backstory about why I had this done, but it's not important to this post. The important thing is a high CAC score means you need further testing to see if there's blockage.

My doctor put in a request for approval of both a nuclear stress test and echocardiogram to get a better idea of how heart was functioning and if there is any significant blockage in my coronary arteries. I thought this was a "slam dunk" given how high my CAC score is.

Well, I found out my insurance company (United Healthcare) uses a third-party provider named eviCore when radiology or cardiology tests are needing pre-authorization.

I got a letter from eviCore today saying both tests were denied (see attached file for a highlights of the important parts of that letter).

I sent a message to my cardiologist through their web portal to see where to go from here. Hopefully he's dealt with b.s. like this before and has a way to get this approved.

Insurance companies have no problem at all taking your money every month to pay for your insurance policy, but when you need a procedure, they all too often come up with some excuse to deny it. What a racket.

Has anyone here had to deal with eviCore with something similar to this?

My wife and I decided to switch from BCBS to GEHA/United Healthcare this year because we liked their plan better (and they were cheaper too. Now I know why. They don't want to approve medically necessary procedures!). Wish we hadn't left BCBS now. Guess we'll be going back to them next year. My wife had NO problem getting a nuclear stress done last year due to some breathing issues.

Any info anyone can provide is appreciated. I'm getting together some info now and plan on appealing this unless my doc has a way to get it pushed through.

Andy

Shared files

eviCore (eviCore.pdf)

Interested in more discussions like this? Go to the Heart & Blood Health Support Group.

@hikerguy62 Welcome to the world of playing roulette with health insurance. I am assuming from the plans you mentioned that you are a Federal retiree. Let me assure you that BCBS has been worth every penny to my husband and me. Once paired with Medicare Parts A & B, there are no copays except for medications and plenty of perks. I have had exactly one denial in over 5 years (dealing with a pretty long list of medical issues for both of us. )
I don't know where you are located, but United Health Care, and their partners don't have a very good reputation among my senior friends in Minnesota and Texas.

My daughter had no choice but United with one of her employers, and she found appeals by the daocs were successful more often than not, so it certainly is worth a try.
Sue

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Thanks for your reply Sue. My wife is a federal employee and I'm on her plan. We never had issues with BCBS but after looking at everything during open enrollment last year, it seemed GEHA might be a better choice and decided to give it a go. Now I'm seriously doubting that decision. It's just unfortunate I didn't find out about my heart issue while on BCBS. We would have stayed with them then.

It's good to hear that appeals can work. I'm hopeful my cardiologist has ran up against this before. If he runs into roadblocks, I'm still going to appeal myself. I've already found some good info on Mayo Clinic's and Harvard Health's websites about CAC scores and high risk of heart attacks and other "cardiovascular events". I need to know if there's severe blockage in my coronary arteries to determine if I need stents or not. One test for that is the nuclear stress test. I'm not going down without a fight. I'm not paying some company money for nothing.

My wife found the following eviCore website. It's like a series of "canned answers" as to why they'll deny claims. If you go to this link, you might have to refresh the page a few times (press F5 on your keyboard). I had some issues getting it to display last night and had to refresh the page several times. It's an interesting read.
https://www.evicore.com/insights/the-8-most-common-inappropriately-ordered-tests-and-why-theyre-being-denied
If we had known that by going with GEHA we would have to work with not just GEHA, but also UHC (United Healthcare) and eviCore, we would have stayed with BCBS. From what I understand, UHC processes the claim, GEHA pays out the claim, and eviCore is used for all pre-authorizations for all cardiology and radiology procedures. BCBS was SOOOOO much simpler. You just dealt with them.

Unfortunately, my take-away from all this is "Just give me your money and shut up".

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Hi Andy,
I have experience with UHC in a similar situation. I had a CT Colonography that my Doc assured was covered. It was denied. After a few months the provider turned me over to a collection agency and I paid the $865 and appealed it to UHC. In about three months UHC decided I should be given a refund for the full amount. A UHC
" executive decision". They sent a check to the provider and they forwarded it to me. Case closed.
I learned 2 things from this experience. Prior to having a procedure get the procedure "code" and "description" from the provider and run it past your carrier to see if it's covered and for how much $.
The second thing is "the squeaky wheel gets the grease". Sad but true.
I must have phoned several UHC support groups before I connected with the right lady who did a great job of pushing my appeal through UHC.
Tadueo

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Hi again tadueo,

Yes, my wife told me to make sure I got approval before going in for these procedures. It's a good thing I did. I think I'll get it approved in the end based on my calcium score (2543). I got a call from my cardiologist's office on Monday saying they had fax'd over my calcium CT scan and hope to get it approved this week. Why they didn't include this very important info to begin with is a mystery to me, since I uploaded it into their system prior to my first visit. I'll update once I find out something. I don't intend on letting them deny this approval. This is absolutely medically necessary to determine how much blockage there is in my coronary arteries.

I'm can be a VERY squeaky wheel if need be 🙂

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@hikerguy62
15 years ago I worked briefly for CareCore that became EviCore.
It was very frustrating at times especially when tests ordered by a specialist were denied. That doctor then had to waste time calling and speak to someone and most often got an approval.
Of course there were times when a denial was justified- it most often were cases when they didn’t submit important information.
In your case the calcium score CT was not submitted.
From my own experience working in a medical office majority of these prior approval requests were done by office staff that didn’t realize the importance of including important reports.
I hope you have gotten your approval by now.

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I got a call from my cardiologist's office stating that they got authorization for both the echo cardiogram and nuclear stress test. I also got a letter from eviCore showing approval for the stress test (but never got one for the echo, so I'm hoping Duke has me covered for that test). Having the doc's office sending the correct supporting docs is VERY important. Still don't understand why they didn't do this to begin with.

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