Frequently Asked Questions About Insurance
Will my insurance company or health plan pay for MRgFUS?
Coverage of MRgFUS will vary by payer. MRgFUS may still be considered a new technology for treatment of uterine fibroids since FDA approval in 2004. Because some payers view this treatment option as relatively new, payer coverage policies may not include the MRgFUS procedure. It may be necessary for you to contact your health plan to verify MRgFUS as a covered benefit under your plan policy.
Do I need to get pre-certification/prior authorization before treatment?
Pre-certification is recommended for all surgical procedures, including this non-invasive, non-surgical procedure. You or your physician’s office should contact the health plan for pre-certification of MRgFUS treatment prior to scheduling the treatment. Your plan may also require pre-certification for any pre-screening tests required to confirm that you are an appropriate candidate for MRgFUS. We suggest you work with your referring physician and/or staff at HIFU of Westchester for assistance in your pre-certification efforts.
What should I do if my health plan denies my request for MRgFUS treatment in this pre-certification/prior authorization process?
If you complete the pre-certification process and your plan does not consider MRgFUS a covered benefit (or medically necessary) and denies your request for treatment, you are entitled to initiate a patient grievance. Contact your health plan to obtain information regarding the grievance process. You will be required to follow the plan grievance process. You may also be entitled to a second, more formal independent review process if your health plan denies treatment under the grievance process. Request documentation from your plan that outlines your grievance and appeal options in detail.
What if my grievance and appeals have been exhausted?
Once you feel you have exhausted all options for appeal, you may consider other options for MRgFUS treatment. Under some health plans there are legal remedies available by state, federal, or ERISA regulations. For those who seek treatment outside appeals or legal remedy, self-pay options may be considered. GE Healthcare’s Care Credit subsidiary offers financing to qualified individuals and HIFU of Westchester offers a self-pay program for patients desiring treatment.
