CRS Legislative Updates

The CRS continues to push for coverage of DBT by private insurers.  Existing law requires insurers and plans to cover all screening and diagnostic mammography services ordered by a physician but almost all are denying coverage for DBT claiming it is investigational. Though our sponsored bill AB 2764 (Bonilla) stalled in the Assembly fiscal committee in recent weeks the following has occurred;

• CRS has sent letters to both the Department of Managed Health Care and the Insurance Commissioner requesting that they require plans and insurers to cover DBT without patient cost sharing based upon federal law and the ACA.
• CRS representatives met with the medical directors and contract staff for both Blue Shield and Anthem Blue Cross to urge them to alter their medical policies and cover DBT. We met with Anthem at the offices of DMHC and they indicated their concern with the high number of IMR requests by patients.
• DMHC website shows 376 IMR decisions involving DBT and 93% of those decisions overturn the plan denials. DMHC stated that another 400 IMRs were in the pipeline for review.
• CIGNA announced that effective Aug. 23, 2016 that they would cover and reimburse for DBT.  

We know that some groups are encouraging their patients to utilize the DMHC IMR process to appeal the denial of coverage. We suggest that all radiology groups who provide DBT continue to help their patients. DMHC is aware of the issue and recommends that any patient who is denied coverage of DBT by their plan can submit a simple one-page form requesting IMR review.

Since the denial is made by the plan on the basis that the procedure is "investigational" the patient can use the IMR process without having to appeal internally to the plan. Given the current 90% or greater denial rate for DBT by health plans as "investigational or experimental" we have the opportunity and should empower our patients to go straight to the Independent Medical Review process of the DMHC to obtain satisfaction at two levels.  First the denial will be overturned and second the cost of the entire process of review goes on the health plan. Some radiology providers are seeing plans reverse course and pay for the service once an IMR is filed.

The IMR process can bring the plans to awareness quickly if thousands arrive.  Each center should make a vow to Inform, Sign, Retain, and Send in a minimum of 100 IMRs each week.

The process of submitting on behalf of patients their IMRs for DBT.  Please proceed with:

1. Informing patients at the Time of Service why we are standing with them on the fight against breast cancer by having them sign at the time of service, their authorization for IMR on the full expectation of a coming denial for DBT.
2. Obtain signatures on the IMR form (DMHC website) from patient signature line and "authorization to assist" signature line.  Two signatures here.
3. Retain their form in center on their behalf awaiting notification of denial of payment by their health plan
4. Submit IMR to the DMHC upon receipt of denial on behalf of the patient

The four step process for each center would then be: Inform, Obtain signatures, Retain, Submit upon notification of denial. We have included a copy of an explanatory form being used by one radiology group to educate their patients. It might be useful as a template for what DBT providers can use with their patients.

Since the Department of Insurance (DOI) also regulates some heath care insurance policies they may have jurisdiction. DOI mostly regulates PPO products and on their website they also have an electronic means for either a patient for file an IMR or a provider to file a complaint over a lack of coverage. Please go to www.insurance.ca.gov and click the link for consumers. The insured's insurance ID card may indicate the type of insurance or the patient can ask their insurer who has jurisdiction over the policy.