On April 2nd I was out running, tripped, and landed on my hands (FOOSH). The next day I woke up in significant pain in my left hand. Went to urgent care, where they suspected a scaphoid fracture — X-ray and CT scan both came back looking normal.
Fast forward a month later and my hand still hurts and I have a vacation coming up. My PCP couldn't see me in time, so I saw someone on Sesame Care who gave me a referral for an MRI of my left wrist. Sesame care does not deal with insurance at all, so they did not submit any sort of pre-approval request. I called around, found an imaging center that could fit me in that week, and paid out of pocket (facility fee + radiologist fee to read the images and write the report). Results showed a small incomplete fracture of the dorsal triquetrum with marrow edema — not the scaphoid, but something.
I went back to urgent care the next day (which was yesterday) with the MRI report in hand. They gave me a brace and a referral to an orthopedic doctor.
Now I'm wondering: is it worth submitting a claim to insurance for the MRI knowing what I know now? I didn't get pre-authorization because of the vaction time crunch and the online doctor that gave me the referral and was fully prepared to self-pay (and I paid the imaging center at time of service). Since the scan found something, it seems like it might be worth trying to submit (can medical necessity be determined retroactively?).
Worst case is that they deny it and I'm no worse off, right...or will this blow up in my face in some other random way because of the machinations of the health care system?
If I do submit, I only have a receipt showing "Patient Pre-Payment Elective" and a receipt for the radiologist fee that is just a generic receipt. Is that sufficient along with the referral and MRI results, or should I request an itemized receipt?
My insurance is Premera Blue Cross if that matters. Since the submission guidelines want receiepts ... here's what I have (with identifying info censored):
(I found cheaper places to get an MRI, but none that could fit me in on the timeframe I was looking for)
edit: looked at my plan documents and here’s what it has to say about prior auth: screenshot