How to Get Your Prostate MRI covered by your Health Insurance

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(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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by Dr. Geo

2 comments… add one
  • Richard Gonzalez ,

    Dr Geo,

    Is a MRI fusion and a MRI guided biopsy the same?

    Thanks, Richard

    Reply
    • Hi Richard. Yes, those two terms are used interchangeably.

      Reply

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