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Insurance won’t pay for BRAF test

Forums General Melanoma Community Insurance won’t pay for BRAF test

  • Post
    KatyWI
    Participant

    My oncologist sent out a tumor sample for BRAF testing (I was negative).  My EOB came back denied as "not medically necessary."  As far as I can gather from talking to the insurance company, the bill is coded as genetic testing, and they only cover genetic testing for a few very obscure conditions (none of which I have!)  Has anybody had any luck appealing in this kind of situation?  What was your doctor's argument that it should be covered?  I have BCBS of GA (yes, despite living in Wisconsin.  Beats me how that works.)

    KatyWI

    My oncologist sent out a tumor sample for BRAF testing (I was negative).  My EOB came back denied as "not medically necessary."  As far as I can gather from talking to the insurance company, the bill is coded as genetic testing, and they only cover genetic testing for a few very obscure conditions (none of which I have!)  Has anybody had any luck appealing in this kind of situation?  What was your doctor's argument that it should be covered?  I have BCBS of GA (yes, despite living in Wisconsin.  Beats me how that works.)

    KatyWI

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  • Replies
      lhaley
      Participant

      Katy,

      Have the oncologist resubmit with different coding. Mine was done after my last surgery in October and it wasn't even questioned. I also have BCBS, mine is from Delaware but I live in SC!!  Before they sent mine I asked if it was going to be an issue and the onc went out of the room for a minute to ask. He came back and said that they hadn't had any issues.  This is medically necessary to plan your treatments!

      Good luck,

      Linda

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      lhaley
      Participant

      Katy,

      Have the oncologist resubmit with different coding. Mine was done after my last surgery in October and it wasn't even questioned. I also have BCBS, mine is from Delaware but I live in SC!!  Before they sent mine I asked if it was going to be an issue and the onc went out of the room for a minute to ask. He came back and said that they hadn't had any issues.  This is medically necessary to plan your treatments!

      Good luck,

      Linda

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      washoegal
      Participant

      I've had BCBS of CA deny things for the very same reason.  I've appealed them and they have paid.  I think they just do it out of routine and figure they will get away with a certain % of them.  Like we need more stress!  This is one place I wish "reform" would help but I am afraid it going to get a lot worse. 

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      washoegal
      Participant

      I've had BCBS of CA deny things for the very same reason.  I've appealed them and they have paid.  I think they just do it out of routine and figure they will get away with a certain % of them.  Like we need more stress!  This is one place I wish "reform" would help but I am afraid it going to get a lot worse. 

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      premedy
      Participant

      katy,

       if you don't mind me asking how much does the braf test cost? I  am probably going to run into the same issue so was just curious.

      pat

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        theonlydrea
        Participant

        I agree call the medical billings department  have them resubmit with a diffrent coding to the insurance. My husband is double insured and both of our insurance companies covered his braf test. It is definitely medically necessary it helps determine  what may or may not work for you. If that doesn't work then you need to file a disbute with the insurance company and fight it.

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        theonlydrea
        Participant

        I agree call the medical billings department  have them resubmit with a diffrent coding to the insurance. My husband is double insured and both of our insurance companies covered his braf test. It is definitely medically necessary it helps determine  what may or may not work for you. If that doesn't work then you need to file a disbute with the insurance company and fight it.

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        MichaelFL
        Participant

        Here is a post from about a year ago, maybe it will help some.

        Michael

        Posted by Sharyn at 04:55 on Sun, Apr 04, 2010 [Show other posts by Sharyn]

        In Reply to: Sharyn or anyone : cost for genetic testing? by curious posted at 09:06 on Fri, Apr 02, 2010

        Sorry, Curious; I've been away for the Easter weekend. I had genetic testing for BRAF, NRAS and KIT mutations, and it cost $2,550 US. I'm surprised, though, that a lot of the above responders got theirs for free. There are different cominations of tests you can have done, or just individual ones.

        KIT – $1740

        BRAF – $660

        NRAS – $930

        HRAS – $930

        GNAQ – $660

        GNA11 – $660

        I don't know if insurance will cover this. It's different in Canada. I have to get approval from MCP (Provincial Medical Care Plan) that it was a necessary test, and then if they cover part of it, insurance will cover part of it too. Either way, it was worth it to me.

        Good luck

        Hugs

        Sharyn

        Stage IV

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        MichaelFL
        Participant

        Here is a post from about a year ago, maybe it will help some.

        Michael

        Posted by Sharyn at 04:55 on Sun, Apr 04, 2010 [Show other posts by Sharyn]

        In Reply to: Sharyn or anyone : cost for genetic testing? by curious posted at 09:06 on Fri, Apr 02, 2010

        Sorry, Curious; I've been away for the Easter weekend. I had genetic testing for BRAF, NRAS and KIT mutations, and it cost $2,550 US. I'm surprised, though, that a lot of the above responders got theirs for free. There are different cominations of tests you can have done, or just individual ones.

        KIT – $1740

        BRAF – $660

        NRAS – $930

        HRAS – $930

        GNAQ – $660

        GNA11 – $660

        I don't know if insurance will cover this. It's different in Canada. I have to get approval from MCP (Provincial Medical Care Plan) that it was a necessary test, and then if they cover part of it, insurance will cover part of it too. Either way, it was worth it to me.

        Good luck

        Hugs

        Sharyn

        Stage IV

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        KatyWI
        Participant

        Pat, it was $650.  that was from UW Hospital, but I know my doctor sent it out to Mayo to be tested.  I'm a little worried there's another bill from Mayo I haven't seen yet. 

        KatyWI

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        KatyWI
        Participant

        Pat, it was $650.  that was from UW Hospital, but I know my doctor sent it out to Mayo to be tested.  I'm a little worried there's another bill from Mayo I haven't seen yet. 

        KatyWI

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      premedy
      Participant

      katy,

       if you don't mind me asking how much does the braf test cost? I  am probably going to run into the same issue so was just curious.

      pat

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      LynnLuc
      Participant

      I was told the B-raf trial would cover the testing as they prefer to do it themselves…if I wanted to get it done before trying to enroll I would have to pay…figure I will wait until I need it…I do know the Blue Cross/Blue Shield will cover the cost of  HLA typing.

      When I enrolled at Fred Hutchinson for a immunotherapy trial Fred Hutchinson actually paid for the test Immunophenotype report which told me the NY-ESO,GP-100,Mart 1,Mouse IgG1,Tyrosinase from my biopsy.

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      LynnLuc
      Participant

      I was told the B-raf trial would cover the testing as they prefer to do it themselves…if I wanted to get it done before trying to enroll I would have to pay…figure I will wait until I need it…I do know the Blue Cross/Blue Shield will cover the cost of  HLA typing.

      When I enrolled at Fred Hutchinson for a immunotherapy trial Fred Hutchinson actually paid for the test Immunophenotype report which told me the NY-ESO,GP-100,Mart 1,Mouse IgG1,Tyrosinase from my biopsy.

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