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

10 comments… add one
  • Richard Gonzalez 08/15/2017, 10:46 AM

    Dr Geo,

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

    Thanks, Richard

    Reply
    • Dr. Geo 09/16/2017, 10:40 AM

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

      Reply
  • Randy 08/29/2018, 3:25 PM

    Outstanding article. I found this at exactly the right time.

    Reply
  • Steve 11/09/2018, 4:45 PM

    I had decided to pay for the prostate MRI regardless of Medicare coverage – and the MRI showed a lesion with an assignation of PIRADS-4. The claim was nevertheless denied, and I was billed $3,750 [Palo Alto [CA] Medical Foundation, part of Sutter Health]. Subsequently, the billing department arranged for the claim to be ‘re-coded’ and re-submitted – and did get covered.

    Reply
    • Dr. Geo 11/09/2018, 4:51 PM

      Awesome for you to share. Thank you.

      Reply
  • Jean-Pierre White 01/10/2019, 5:12 PM

    I was diagnosed with Prostate cancer after a biopsy and am leaning towards Hi-Fu as a treatment. It took over a month to get insurance to agree to pay for T3 MRI *after* the diagnosis of prostate cancer.

    If the MRI shows I am a good candidate for Hi-Fu I will be left to pay that medical bill in full as Hi-Fu is not covered by insurance despite the fact it is less than half the cost of surgery and has significantly fewer side effects.

    It’s hard to get inside the heads of the insurance companies. Its as if they want to halt medical advancement and keep us in the 20th century indefinitely.

    Reply
  • Steve 01/17/2019, 9:36 AM

    Hi, does Medicare cover cost for MP MRI?

    Reply
    • Dr. Geo 01/28/2019, 1:17 PM

      Not yet, before a biopsy (Jan 2019), which defeats the purpose.

      Reply
  • Joe 02/26/2019, 8:21 AM

    Hi, I have been tested with a sudden rise in my PSA FROM 1.9 to 9.2 in 12 months. Having been referred to specialist for further diagnosis I am trying to avoid biopsy for the reason of avoiding needle seeding of cancer cells should they exist. My question is if I do get a MRI and it shows up something how could I avoid the targeted biopsy. I believe biopsy’s have a real concern for cell seeding in other areas as it is researched.

    Your thoughts on this please.

    Reply
    • Dr. Geo 03/01/2019, 8:36 AM

      Hi Joe, although I understand your concerns, there is no other method of diagnosing for prostate cancer, at this time, other than a biopsy. If you choose not to get a prostate biopsy, there is a risk of having prostate cancer and not knowing it, which that is a risk some men take and others don’t.

      Reply

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