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Any experience dealing with eviCore? Medical procedure denied!

Posted by hikerguy62 @hikerguy62, May 12, 2023

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)

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andytheman | @andytheman | Apr 17 5:15pm
In reply to @maryc3d "I had breast cancer (stage IIB with lymph node involvement). I have really bad chest pain,..." + (show)
@maryc3d

I had breast cancer (stage IIB with lymph node involvement). I have really bad chest pain, and had a CT scan which showed, "Lytic lesions with ill-defined borders involving the entire chest with extension to and loss of integrity of the posterior vertebral body cortex. These findings can be seen with metastatic disease. Recommend PET/CT for further evaluation. " My oncologist ordered a PET/CT which was scheduled for 4/12 (tomorrow), but BP/AETNA/EviCore denied coverage, and the imaging center called to cancel the appointment. If EviCore reverses their decision after my appeal, the earliest the imaging center can fit me in is May 7th. This is a 3-week delay in treatment.

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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

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