Insurer approves, then denies MRI, forcing man to pay $2,340 out-of-pocket

Patients’ wishes and insurance companies’ approval don’t always line up when it comes to coverage for imaging procedures, the Philadelphia Inquirer reported this week.

Keith Morgan, 56, had been dealing with pelvic pain for two decades when he decided to go forward with a pelvic MRI, the Inquirer reported. The procedure was one that required prior authorization from Philadelphian’s insurance company, Independence Blue Cross, meaning Morgan’s doctors had to submit details about the procedure and its necessity.

Morgan’s MRI was approved by Blue Cross for a scan at the Vincera Institute in Philadelphia, but after being pulled between practices for so long, he decided he felt more comfortable undergoing the MRI at Penn Medicine, where his other doctors were based.

Blue Cross quickly denied Morgan’s second request for the same MRI—this one coming from Penn—telling him an x-ray was required first to rule out arthritis, followed by a handful of physical therapy sessions to reduce pain. Only then could he re-submit a request for MRI coverage.

“There’s something flawed here,” Morgan told the Inquirer. “You can’t have a doctor with a patient in need denied coverage after a physical exam, whereas miles away in the same city a doctor gets approval without even an appointment.”

To go ahead with the procedure, Morgan said he doled out $2,340 out-of-pocket.

One Blue Cross physician said even though it might feel like insurance companies are bullies, they’re doing what they feel is right for the patient.

“We really, truly—whether someone believes us or not—are trying to look at that patient safety issue in terms of what’s the best care and following the evidence-based standards,” Virginia Calega, Blue Cross’ vice president of medical management and policy, said.