(Image from Medscape 2017)
Despite the fact that the multi-parametric MRI can prevent almost 30% of men from an unnecessary biopsy , health insurance companies are on not covering the cost.
A negative MRI – where no suspicious lesions are seen has a powerful potential of detecting clinically significant disease. If a high-quality MRI is negative it means the chance you have high-grade disease is low.
If the MRI shows areas in the prostate suspicious for cancer cells, a targeted biopsy, MRI fusion biopsy is the best way to go.
What’s the benefit of a MRI guided biopsy? The technique fuses MRI images with ultrasound imaging to create a detailed, 3-D view of the prostate. This improved view helps physicians perform biopsies with much higher precision than blind, ultra-sound guided biopsy and increases prostate cancer detection that can be serious.
The problem is your health insurance is not covering MRI cost before a prostate biopsy.
How to get a Prostate MRI covered by your Health Insurance
These tips are based from conversations with members of my billing department and physician’s I have spoken to throughout the country:
• Your doctor, the physician’s Nurse Practitioner (NP) or his Physician’s Assistant (PA) has to make a peer-to-peer call to your insurance company and try to have them cover it.
• The physician’s office is typically reluctant to call your health insurance company as that can take up to an hour of the practitioners time.
• The more data you have suggesting a higher likely of prostate cancer, the likelihood of getting it covered. In other words, things like a PSA over 10ng/ml, a positive 4Kscore or PHI score can help get it covered. Your doctor or a practitioner from his / her office still has to make such peer-to-peer call.
• If you pay up front and get the MRI done followed by a prostate biopsy showing cancer, you are likely to get reimbursed.
• The cost from a mp-MRI is about $1300.00 and ranges from $700 – $1500 depending on diagnostic facility. However, like buying a car, that amount is negotiable up to $500 less.
MRI rejection makes no sense financially – since biopsies and subsequent related treatments, i.e. 4% post-biopsy infections, treating indolent low-grade prostate cancer and prostate cancer treatment side effects can be even more expensive.
Bottom line: MRI helps identify prostate cancer we should worry about (most prostate cancer are low-grade and will likely never kill you); helps with obtaining a better biopsy (targeted biopsy); health insurance companies are not covering the cost of prostate MRI, although the fee is negotiable; any possibility of coverage is dependent on your particular case delivered by your practitioner.
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