Tips for an insurance pre-appeal?

I’m wondering if anyone has advice on how to do a pre-appeal to my insurance company.

Here’s the deal. My insurance policy sucks in regard to mammograms. Per our policy, a mammogram is covered for a $25 copay if the mammogram is done as part of an office visit.

If it is done at a lab, however, I will be liable for 20% of the cost, as outpatient lab fees are subject to my co-insurance.

I have asked both my GP and my gynecologist, nurses I know, and family members if anyone knows of anyone in my metro area that has an in-office mammogram machine. No one does.

I have one place I’m trying to get ahold of to see if they are contracted with BCBS to be able to bill a mammogram as an office visit, but I fear they are also considered an outpatient lab facility, so I’m not hopeful.

So. In effect, AFAIK, it is not possible for me to have a mammogram done anywhere in my city except for at an outpatient facility. Therefore, it is not ever going to be possible for me to get a $25 mammogram. Instead, it will end up costing me likely $220 or so. This is how much it cost me when I had one two years ago under this same policy.

BCBS says it is possible to do a pre-appeal for this service and explain why the claim should be processed in my favor. The form is pretty open-ended. It just says tell us why you think this should be appealed. Provide documentation as necessary.

Anyone have any kind of experience trying to get something appealed before you have the procedure done? I know I can appeal it after, but it pisses me off that I have to go have the mammogram done and then hope BCBS will be merciful later. The difference is two hundred bucks, so I figure trying to appeal it beforehand would at least be worth my time.



I’ve been making calls today to try to find a facility that meets the requirements of my policy and I’m having no luck. I think it’s total bullshit, BTW, that no one - not BCBS, not the service providers - can tell me who can code a mammogram as an office visit.

No one.

Would a letter to my insurance commissioner be fruitful? I mean, my insurance provider has stated they provide a service for a certain price, but have made it impossible in practice for me to get that service at that price. Certainly, they know that it is now standard (as far as I can tell) for mammograms to be done in an outpatient lab, and rare to non-existent for a doctor to offer mammograms in his office.