High-intensity focused ultrasound uses non-ionizing ultrasonic waves as a non-invasive technique to ablate (heat) tissue, increasing the flow of lymph fluids or blood, or destroying tumors. The ultrasound waves of HIFU are often used to treat uterine fibroids, cancerous and non-cancerous tumors, including desmoid tumors and osteoid osteomas, as a treatment for prostate cancer, for pain from cancers that have spread to the bones, and as a treatment for essential tremors.
Since the uses for HIFU are generally for serious issues (HIFU can also be used in facelift procedures), if your doctor orders high-intensity focused ultrasound for a health issue for you and your insurance company denies the treatment, it can be devastating. HIFU denied by your insurance can leave you feeling frustrated, even angry. After all, you pay your health insurance premiums faithfully, and now it’s time for your insurer to do its part.
Why Might Your HIFU Treatment Be Denied?
Although insurance companies may cloak denials behind language like “not medically necessary,” “experimental,” or “investigational,” the usual reason a treatment is denied comes down to money. Most insurance companies are concerned about their financial bottom line—sometimes more than they are concerned with the health of those they insure. HIFU treatments can be expensive, just as other types of ultrasound procedures may also be costly.
There are currently a variety of ultrasound procedures as well as two types of HIFU treatments; Magnetic resonance imaging focused ultrasound surgery (MRgFUS) which uses magnetic imaging and ultrasound guided high intensity focused ultrasound (USgHIFU). Most USgHIFU treatments can be completed in one session, however, a patient with multiple or large-diameter fibroids may require several sessions.
What Should You Do if Your HIFU Treatment Is Denied?
For HIFU denied by insurance, you do have options so it’s important that you not give up once you receive the denial letter. Look at your denial letter closely to determine exactly why your HIFU treatment was denied. Your claim may simply be missing some information that can be re-submitted. If, however, your HIFU treatment was denied under the claim that it is not medically necessary or is experimental or investigational, you need solid legal assistance from the Law Offices of Scott Glovsky.
Scott and his highly experienced legal team can help you file an internal appeal with your insurer, ensuring all your paperwork is complete and that you have a detailed letter from your healthcare provider that fully explains the necessity of the HIFU treatment. If your internal appeal is denied, we will help you file an external appeal with a neutral third party if that is the route that Scott recommends. Many people simply accept an insurance denial—you don’t have to do this. The Law Offices of Scott Glovsky will fight on your behalf to ensure you receive the medical treatments you need and deserve.
Are There Some Insurers That Are More Likely to Deny Your HIFU Treatment?
Any insurer may potentially deny HIFU treatment, usually because they don’t want to pay the costs involved—even though you pay your monthly health insurance premiums. If you are depending on HIFU treatment for prostate cancer or another serious matter, it can feel disturbing and overwhelming to have your treatment denied. Some of the insurers who may deny HIFU treatments include the following:
- Anthem Blue Cross
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- As of January 2024, Anthem Blue Cross does not consider HIFU medically necessary except for pain palliation in people with localized metastatic bone pain who meet very specific and narrow criteria. Anthem published its latest HIFU Guideline #: CG-MED-81 on January 3, 2024. This guideline specifies that HIFU is not medically necessary for any other indication including prostate cancer.
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- Blue Shield
- Health Net
- Kaiser
- United Healthcare
- Aetna
- and others
As of January 2023, Medicare covers HIFU.
Is HIFU an Expensive Treatment?
HIFU treatment for prostate cancer can cost from $15,000 to $25,000. Unlike surgery or radiation, HIFU can have far fewer negative side effects for men with prostate cancer. HIFU is a much less invasive treatment that is less likely to result in incontinence and erectile dysfunction than some other prostate cancer treatments. Until fairly recently, some U.S. men diagnosed with prostate cancer traveled to Mexico, the Bahamas, or Bermuda to have HIFU treatments done by U.S. doctors in those areas. Europe has been using HIFU treatments longer than the U.S., and while the treatment is approved in Canada, the national health program does not pay. The FDA approved HIFU in 2015 as a valid treatment for prostate cancer, so it should no longer be considered experimental by insurance companies.
Can Your Doctor Help with HIFU Denied by Insurance?
The “ideal” candidates for prostate cancer HIFU are those who have early-stage, low-grade cancer that is confined to the prostate and that is visible on an MRI or ultrasound. A PSA level below 20 is also generally preferred. Even if you do not fully meet these criteria, your doctor can provide a detailed letter to your insurer that states why you would benefit from HIFU—and the detrimental effects to your health if you are denied the treatment. Such a letter could convince your insurance company to reverse its denial decision.
How Can Attorney Scott Glovsky Help with HIFU Denied by Insurance?
If you are dealing with HIFU denied by insurance, you may be feeling hopeless and overwhelmed. You don’t need to face this situation on your own. Attorney Scott Glovsky and his legal team are ready to help you through this difficult time with the goal of getting your denial turned into an approval. The Law Offices of Scott Glovsky have been helping people in similar situations for more than two decades. Attorney Scott Glovsky is widely recognized as a highly experienced, well-respected, compassionate health insurance denial lawyer who doesn’t give up and who never hesitates to go up against a big insurance company. Contact the Law Offices of Scott Glovsky today for the help you need.