Edit to add: although this thread went off on a big tangent initially, I'd still really like to hear from people about the information I originally requested. To clarify:- the MTHFR lab test has already been done. I appreciate some of the suggestions others have made about using other labs. I hope this thread will help others who may decide to use labs other than Quest Diagnostics which bill less for the MTHFR test. Additionally, verify your insurance coverage before having this particular test if you're hoping it will get covered (of course, insurance companies make this more difficult than it should be and it's particularly problematic if you've traveled hundreds to 1000 miles or more to see one of the few CFS experts and would like to get all the blood draws done at that office. From what I've learned, I'd suggest holding off on the MTHFR test until you can verify insurance coverage - Quest Diagnostics does have blood draw locations all over the US and your physician can write an order for it to be drawn at any of those locations).
I'd also particularly would be interested in information about the dollar amount the insurance company "allowed" and the diagnosis codes that were used when the insurance company approved coverage. (end of edit)
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I'd like to find out what people's experiences here have been with getting health insurance to cover the MTHFR test (CPT code 81291). My physician ordered one and my insurance company denied coverage for it, saying it was "experimental/investigational". Since then, I've discovered that many people's insurance companies have covered the test, so I'm suspicious about how my insurance company denied coverage. (I've been billed $400 by Quest Diagnostics for the test; for all my other lab tests, the amount "allowed" by my insurance company is a fraction (1/8, on average, across several dozen different lab tests) of what the initially billed amount was. If the insurance company successfully continues to deny coverage, I am stuck paying the excessive amount Quest Diagnostics initially bills.)
If you have had the test and submitted it to insurance for coverage, please tell me whether your insurance company covered the test or denied coverage. I'd especially like to hear from anyone who successfully appealed denial of coverage (especially the details). I plan to appeal this, but am unsure how to go about it. I'm far from being an expert in genetics testing. Although I could probably spend many dozens of hours learning about this to try and argue my case in the appeal, I'm not sure it's worth it. But if anyone can give me pointers, that would help. I've never appealed an insurance company's decision before, so I'm not sure what the best strategy is. I know I first go through an "internal" (within insurance company) appeal, and then have the right to ask for an "external" appeal. I did ask the insurance company to send me the "criteria" for their decision. all I got was a very general, 10 page document that sets out all the criteria for "allowable" genetics testing, but does not tell me specifically what factors were used to deny coverage in my case.
Additionally, from reading online, it seems that for this test, with some insurance companies, it may very critical what "codes" (diagnostic, I think) were submitted, but I don't have a clear understanding of this (and it may be insurance-company specific).
I'd appreciate any advice regarding submitting appeals, either general advice, or specific to this case, especially from anyone (physicians, or employed by insurance companies, etc.) who have a strong understanding. (I hope that others will be helped by this thread as well.)
I'd also particularly would be interested in information about the dollar amount the insurance company "allowed" and the diagnosis codes that were used when the insurance company approved coverage. (end of edit)
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I'd like to find out what people's experiences here have been with getting health insurance to cover the MTHFR test (CPT code 81291). My physician ordered one and my insurance company denied coverage for it, saying it was "experimental/investigational". Since then, I've discovered that many people's insurance companies have covered the test, so I'm suspicious about how my insurance company denied coverage. (I've been billed $400 by Quest Diagnostics for the test; for all my other lab tests, the amount "allowed" by my insurance company is a fraction (1/8, on average, across several dozen different lab tests) of what the initially billed amount was. If the insurance company successfully continues to deny coverage, I am stuck paying the excessive amount Quest Diagnostics initially bills.)
If you have had the test and submitted it to insurance for coverage, please tell me whether your insurance company covered the test or denied coverage. I'd especially like to hear from anyone who successfully appealed denial of coverage (especially the details). I plan to appeal this, but am unsure how to go about it. I'm far from being an expert in genetics testing. Although I could probably spend many dozens of hours learning about this to try and argue my case in the appeal, I'm not sure it's worth it. But if anyone can give me pointers, that would help. I've never appealed an insurance company's decision before, so I'm not sure what the best strategy is. I know I first go through an "internal" (within insurance company) appeal, and then have the right to ask for an "external" appeal. I did ask the insurance company to send me the "criteria" for their decision. all I got was a very general, 10 page document that sets out all the criteria for "allowable" genetics testing, but does not tell me specifically what factors were used to deny coverage in my case.
Additionally, from reading online, it seems that for this test, with some insurance companies, it may very critical what "codes" (diagnostic, I think) were submitted, but I don't have a clear understanding of this (and it may be insurance-company specific).
I'd appreciate any advice regarding submitting appeals, either general advice, or specific to this case, especially from anyone (physicians, or employed by insurance companies, etc.) who have a strong understanding. (I hope that others will be helped by this thread as well.)
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