Feature | June 05, 2014

Determined Patient Wins Legal Fight to Cover Molecular Breast Imaging Procedure

Molecular Breast Imaging Coverage Dilon Technologies Mammography

June 5, 2014 — When a health insurance company denies a claim, most people complain to their friends and family and then accept it, arranging payment methods or even denying themselves a procedure that may save their life. However, one patient decided to fight back and challenge her insurance carrier.

When Karen Larson from Golden Valley, Minn., received the news that her new health insurance did not cover the molecular breast imaging (MBI/BSGI) procedure as part of her surveillance program for early detection of breast cancer she put on her boxing gloves and fought.

After discovering a lump in her breast, Karen went in for a mammogram, but the results showed nothing suspicious.  Karen learned that because she had dense breast tissue a mammogram may not necessarily be accurate so she was sent for additional testing. Karen's breast cancer was later detected by MBI, an advanced technology shown by several studies to detect cancers missed by mammography. The MBI technology is provided by Dilon Technologies Inc., which is based in Virginia. Since the MBI proved to detect her cancer, her doctors recommended that she undergo the MBI procedure as part of her follow up surveillance. Unfortunately, her health insurance did not cover the procedure, deeming it investigative and therefore not covered for all applications.

Karen spent weeks appealing the denial to her health insurance provider but was constantly denied. Determined, Karen appealed her case in the Office of Medicare Hearings and Appeals. The judge issued a positive ruling by overturning the denial. The judge's analysis deemed the MBI procedure not investigational and therefore medically necessary for Karen. The ruling was forwarded to her medical insurance provider requesting them to immediately cover her MBI procedure. "I am doing this for myself, my sister and the tens of thousands of other women for whom a mammogram alone is not adequate for breast cancer detection." Karen added, "Women should advocate for themselves and should not take "No" for an answer when it comes to early detection of breast cancer."

For more information: www.dilon.com

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