7 On Your Side helps cancer survivors fight for coverage on life-saving screenings

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Tuesday, February 26, 2019
7 On Your Side helps cancer survivors fight for coverage on life-saving screenings
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Nina Pineda reports on cancer survivors fighting for coverage on life-saving screenings.

So many strides have been made in the fight against breast cancer, including preventative screenings like self-exams, mammograms and MRIs have made early detection a lifesaver.

Survivors rely on tests to make sure their cancer doesn't return, but one victim says she was shocked to find out insurance wasn't paying for a routine followup -- and then Alice Anselmo learned she wasn't alone because this billing battle is apparently effecting scores of breast cancer survivors.

Just one cancer doctor said 90 percent of her patients are getting potentially life saving treatment not covered by insurance -- even though the FDA and the insurance company's own documents say it's warranted.

"I've had six biopsies and lumpectomies so its not like I'm doing this because I'm playing games," breast cancer survivor Alice Anselmo said. She is four years cancer-free, but now she's fighting a brand new battle against her medical insurance, Aetna.

In July, her medical insurance denied a claim for an MRI, billing her, the patient, more than $2,300. But Anselmo isn't paying the bill for three reasons.

"I got pre-approval, you told me it's OK, the doctors says its OK and the FDA plus Aetna has it in writing it's OK," she said.

Three years after Anselmo's double mastectomy and reconstructive surgery, her doctor scheduled a follow up MRI last July and she said they gave her a hard time on the billing -- she says "calling the MRI experimental and investigational and I was like what?"

In writing, Aetna states it only covers services that are necessary.

But check out what we discovered going through Aetna's own clinical policy. Aetna clearly states it "considers breast MRI medically necessary" and refers to the FDA's recommendation that MRI screening should be conducted after implants to "detect any silent ruptures."

But instead of giving up, Anselmo told 7 On Your Side her story of struggle for three more reasons: her daughter, granddaughters and all of the other breast cancer victims who may not get MRI screening because they cant pay for it.

"What could this mean for hundreds of thousands of women? Death," Anselmo said. So she brought her case to 7 On Your Side and we asked the insurance giant to take a second look.

"You guys made one phone call, they decided to reevaluate, you have a powerful say in what happens to a lot of people for the right reason," Anselmo said.

Her MRI claim was approved within a week.

"You guys are the best -- 7 On Your Side is why we got it done," said said. "I just can't thank you enough, you don't know how important this is, Nina!"

Aetna said it had "incorrectly denied" her breast MRI and it's looking into "improving its process" so that these types of denials don't happen again.

The big takeaway -- when it comes to fighting for medical bills, remember you can appeal two times. Your best defense is a doctor's letter that says a procedure is "medically necessary."

You should also check billing codes on your bills to make sure charges are coded correctly.

Here's a full list of all the codes.

Aetna released the following statement:

"Upon review of Ms. Anselmo's appeal, it was determined that the member's breast MRI was initially denied incorrectly even though the procedure was clinically appropriate. The denial has since been corrected and overturned. We are committed to improving our process to avoid a similar denial in the future."



Do you have an issue with a company that you haven't been able to resolve? If so, 7 On Your Side wants to help you!

Email 7OnYourSideNina@abc.com, or contact Nina on her Facebook page or tweet her at Twitter @7OnYourSideNY! You can also call the 7 On Your Side Hotline at 917-260-7697 or fill out the form below.