"Not Medically Necessary"

[u/naturalbuilder08]

Anthem just denied the claim for my childrens genetic test and deemed it "not medically necessary".

I have a 9 year old and a 5 year old who both around the same age (both were 3 son & 4 daughter) had a life threatening event happen after getting the flu, called Rhabdomyolysis.

I won't go through the story of the week long struggle of finally getting a diagnosis for my son but I will state that it went long enough to do some damage. When it happened to my daughter it was like deja vu and I was like there's no way! To be on the safe side I went to the ER with her immediately and after an 8 hour wait... they confirmed it was the same thing before admitting us.

It's rare for it to happen to one, extremely rare for it to happen to both biological children.

Every doctor I've spoken to says that we should get testing to see if there is a genetic component and be able to combat any future issues. We were referred to a genetics hospital. They sent out the order for the testing.

I pay for the drive, the hotel room to stay for the appointment, I pay for the food while we travel and entertainment to make it more fun and... I pay for health insurance...

Just opened it today. It's so exhausting. I pay over $1400 a month for health insurance and have a 5k deductible. The test cost $1500.00... Our genetics team was only testing my son first to avoid any pushback. Then would test my daughter if anything came back wierd.

If they won't cover it, I will pay it myself obviously, if my kids doctors seem concerned, I am too. Its my job to protect them. How is this not medically necessary?

I'd have been better off to not pay a premium the past 5 years and just put the money into a bank account between the deductible and the monthly premium cost.

**Editing to just say thank you for all the responses. I will call tomorrow <3 I really appreciate everyone's help and taking a couple mins out of their day to respond. If I have to pay for it, I will... it's just a defeated feeling I guess. Thank you.

[u/Own-Competition-2250]

In my experience it will come down to the doctors office. How well they document and push for coverage. We fought blue cross for years to get my daughter’s testing covered for multiple genetic conditions- including a rare genetic type of diabetes.

Now that she’s in college with her own university coverage- certainly not the Cadillac coverage of blue cross when her new doctor wanted genetic testing we said you can try but the insurance will never cover it and it’s just not something we can afford- she said let me try - I’ll submit whatever they need. 2 weeks later her office called to come in for the blood work she got it approved. A few months later- $4500 of genetic testing covered for the cost of a lab draw copay.