Trouble with Medicare

[Ilovejoe]

Hi,

A little frustrated here. I have 2 liver diseases being diagnosed with PBC and NASH in 2020. In January 2022 I had a MRE and my liver was F0 with no fibrosis. This past March I was not approved for another so I had a MRI of my abdomen. There were a few concerns and my hepatologist didn’t like how the radiologist reading the test said my liver had cirrhotic features but didn’t state what the features were. There is also something small on the liver but I was only recommended to get another test in 6 months. My doctor is fighting for a MRE but it was denied twice. Has anyone here been denied an MRE that has PBC (autoimmune of livers bile duct)and NASH? What was the outcome? I have Aetna/Medicare if that makes a difference. Thanks in advance,

[nash2 Partner]

I don't have any experience with PBC but it may be more confusing than you suggested. A diagnosis of F0 is no NASH so it maybe should have said NAFLD or fatty liver. MRE is designed to measure liver stiffness and if your insurance sees F0 they see no reason for an MRE. You might ask for an MRI PDFF which measures fat or a cheaper test is FibroScan which gives both fat and stiffness.

[Ilovejoe in reply to nash2]

thanks Wayne. My hepatologist wanted to do another test in April or May so I’ll write to him (because I haven’t heard from him) and suggest one of them!💐

[SailorDude]

As nash2 stated with the MRE diagnosis of F0 means you have no Fibrosis (scarring) or detectable liver stiffness, which is awesome. You're NASH diagnosis is unwarranted. When you had your MRE in 2022 you should have also had an MRI of the abdomen, plus a PDFF for a fat measurement. I believe CMS (Medicare) sort of views these procedures akin to going to a dentist for a teeth cleaning and while you're there the hygienist flosses your teeth and you're offered a fluoride treatment, all at the same cost. I've read some of Aetna's refusal to authorize additional MRE authorization and it is based on legacy/outdated logic. I'm also on Medicare (traditional) and these tests are not as restrictive. Furthermore, like you, I recently had the trifecta (MRE, MRI ABD & MRI PDFF) performed at a specialized national liver research facility. CMS estimated the cost to be $48 and it was actually $42. Your problem is Aetna's limitation on their Medicare Advantage plan. Run and this coming December, seriously consider getting traditional Medicare and a Part D drug supplement and a Medicare supplement plan. In regard to your PBC, in most cases, this is a slow progressing process that goes through several stages before it becomes terminal. Furthermore, when caught early there are treatments to slow down the progression of PBC and improve your condition. Again, on a positive note, F0 is a stage that individuals would have with a healthy normal liver. Finally, you mention there is also something small on the liver. This could be a cyst which in all likelihood is benign. There are several exam protocols which may be appropriate as your conditions progress. Don't limit these options to what an insurer dictates. I've had similar diagnoses, whereby a FibroScan indicated I was on death's doorstep and a FibroSure indicated marked improvement. Your physician is the best judge of how to proceed in the future and a second opinion is also highly recommended in matters such as this. Good luck!

[Ilovejoe in reply to SailorDude]

thank you thank you thank you! What a detailed informative post that gives me a lot of choices and ideas of how to go about getting what I think I deserve. I have this coverage through my NJ teacher’s insurance with Aetna. I will look for another plan if available. I will update when I know more. Thanks Sailor Dude!