Insurance denial for tests

[lupus1315]

Husband needs another MRI to rule out brachial or TOS but a insurance has denied the test stating they feel it is not life or death. He had one of his back 3 months ago when they were thinking pinched nerve. Now his 2nd EMG shows abnormalities in his arms and legs. ANY thoughts suggestions of what we can do???? His twitching is getting worse. He lost all muscle in right arm and chest. And will not pass his CDL, so he will not be able to work without it. Help!!!

 

[Atsugi]

You are trying to detect/rule out TOS with this MRI. How does that relate to ALS?


EDIT to add: Please don't misunderstand. I'm curious. Is your doctor looking for brachial amyotrophic diplegia?

 

[lgelb]

Mike, thoracic outlet syndrome is one of the ALS mimics. BAD, depending on how used, moves into the flail arm variant of ALS.

Lupus (hope you don't have it?), have the neuro appeal the denial and specify explicitly that motor neuron disease/ALS is a differential. But if you are not seeing a neuromuscular specialist at UI (whose office should be good at these appeals), I would not proceed locally but rather forward all records there and arrange a second opinion including any needed further testing so as not to delay things further. As you say, you want the diagnosis resolved.

I very much hope TOS is the answer, but EMG abnormalities in the legs argue against that. Whatever happens, we will support you however we can.

Best,
Laurie

 

[lupus1315]

Thanks Laurie. Iowa city hospital nurse and I have been going back and forth about MRI. His neurological Dr there at first said he didn't think ALS, but after his EMG, that took 1 hour 45 minutes he said when dealing with ALS, before confirming anything, they will try to rule out other possibilities. So we actually do not have a confirmed answer of ALS. Very frustrating and worrisome.

 

[lupus1315]

Sorry, nurse and I have been going back and forth with insurance company. We both call them everyday I think. They at 1 point told nurse that it was not life threatening, and she replied, "you think ALS is not life threatening" The person ignored the comment.

 

[lupus1315]

A brief summary of symptoms. He started getting cramps in hand, then he couldn't lift his 3 middle fingers up and hard time gripping completely. Figured carpal tunnel. A few months later he lost all muscle in his hand, arm, and right bicep and right side of his back shoulder, at that point we went to a Dr. From there sent to a neurologist in Dubuque, who sent us to neurologist in Iowa City. He now has twitching pretty much in his entire body. He also has weakness in his right arm. Like he fishes, but has a hard time throwing line out, or another example is we have a nerf basketball hoop in house for grand daughter, he has to be right at basket to make it or he can only throw it half way there. Does this make sense.

 

[Atsugi]

Yes, Lupus1315, that does make sense, and it's not good. It's not necessarily ALS, but the EMGs should have shown that one way or the other. You need to get the results of both the EMGs and ask a neurologist directly if they see ALS in those reports, just to be sure.

 

[lgelb]

If you are calling the payor every day, you are not reaching the right level of person. As soon as you get someone on the phone, inform her/him that you are done talking to her level and need assignment to and to speak with a case manager. Look up the medical director for your area; get people involved on social media and tap your network for connections to the plan; talk to your local ALSA/MDA/the University clinic.

Is the MRI he needs of a part he has imaged before? Has his C-spine/chest been done already? I would have thought the EMG more definitive in differentiating a brachial complex.

Can you quote here the summary from the last EMG?

 

[Nikki J]

Ask the neurologist to do a " peer to peer" review with the insurance. At least around here there are physician reviewers who work for the insurance company. Your doctor would present the reasons for the MRI and if approved the authorization code is given immediately

 

[lupus1315]

He had a MRI of his back in October, thought a pinched nerve. Iowa city wants, I believe, an MRI of his spine, and his front. Also an xray of his neck. As for summary of EMG we were just told there were abnormalities in both arms, and legs. Before we left, Dr said when dealing with ALS, we always try to find something else to rule it out. Next appt with Dr is March 1st that is why we are pushing for MRI to be done before that appt.

 

[lgelb]

Dubuque, as you know if you've been reading, we recommend that you ask for a copy of the actual EMG/MRI/any other labs or report. Health is too important not to know what's going on, and if you don't hold onto everything, there may not be any other complete record.

Is the March 1 appt in Iowa City?

 

[lupus1315]

Yes. And we will. Thanks for all your advice. I am calling insurance tomorrow and asking for a manager or the person who decides. Thanks to all of you for your help

 

[gooseberry]

One thing I have had to do in the past, is go onto our insurance site and look for policy bulletins etc. I printed out the ones supporting our claim and sent them back to insurance. It solves the problem pretty quick

 

[lupus1315]

Husband is finally getting MRI. One of his brachial plexus, and another of his spine with and without dye. He is also having Xray of his neck.. this will be Thursday, February 18th. Will not get results until March 1st. Thanks for all your support. It will be a very long two weeks. God bless to all!

 

[lgelb]

Glad to hear. Keep us posted.