Can an insurance company deny to cover a breast MRI in the case of possible silicone implant rupture?

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Can an insurance company deny to cover a breast MRI in the case of possible silicone implant rupture?

I am electing to have breast implants and am considering having silicone. This is my one concern. Although rare if suspected an MRI is the only way to tell and this can get pricey.

Asked on October 16, 2010 under Insurance Law, Florida

Answers:

M.T.G., Member, New York Bar / FreeAdvice Contributing Attorney

Answered 10 years ago | Contributor

Insurance companies make a determination as to approving or not approving procedures requested by a doctor by using a term we have all come to hate: medical necessity. 

“Medically Necessity” means health care services and supplies provided by a health care provider appropriate to the evaluation and treatment of disease, condition, illness or injury and consistent with the applicable standard of care, including the evaluation of experimental and/or investigational services, procedures, drugs or devices.  But what you and your MD think may be medical necessity, the Medical Director of your insurance plan may not.  It could be denied and it could be appealed if that were the case.  How good you are at docu,eting the matter and fighting the powers that be will also detemine if it is approved.  The fact that the treatment is part of an elective surgery you had should NOT be a factor in deciding if the treatment is necessary. Good luck.


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