Patient Insurance Appeals | MicroGen Diagnostics

Patient Insurance Appeals

What is MicroGenDX?

MicroGenDX provides qPCR+NGS sequencing for the detection of infectious diseases. The American Medical Association (AMA) and Medicare have issued a billing code to MicroGenDX to provide this testing service, recognizing this technology as medically necessary. MicroGenDX is trusted by over 39,000 physicians worldwide and has helped over 900,000 patients with diagnostic testing for their chronic and life-threatening infections.  

MicroGenDX is the only provider of this test with an approved billing code. As such MicroGenDX testing may be considered out of network to patients whose providers have utilized our technology. This test is not obtainable in any in-network lab (such as LabCorp or Quest Diagnostics) and your insurance provider may not yet be contracted with MicroGenDX.

Whether MicroGenDX testing is covered by insurance may also depend on the specific insurance plan and the reason for the testing. Patients can contact their insurance company directly to determine if MicroGenDX testing is covered under their plan, and if so, what the patient's financial responsibility would be. It's important to note that even if a patient's insurance does not cover MicroGenDX testing or only covers a portion of the cost, there are options for financial assistance through payment plans offered by MicroGenDX.

If your provider prescribed you MicroGenDX testing it is because they believed it was necessary to solve your chronic, recurring, or life-threating infection. You have a right to this testing and your insurance company should be obligated to cover it. You are your own best advocate for coverage. MicroGenDX suggests that you reach out to your insurance provider to demand coverage for your testing. Instructions on how to do that are below.

What should I do if my insurance does not cover my MicroGenDX test?

Exercise your right to advocate for yourself and take a stance on the medical care you deserve by filing an “Appeal of Coverage” with your insurance company. MicroGenDX stands ready as a reliable partner in this process, helping ensure that you can receive quality healthcare without delay or obstruction. Sample letter templates for you to use are below:

Private Insurance Appeal Letter Template

Medicare Appeal Letter Template

Word Doc Version

PDF Version

Printable Version

Alternatively, kindly adhere to the following guidance:

  1. On a web browser search “(Insurance Company Name) appeal insurance coverage.” Most companies will have a page detailing what steps you should take to ask for coverage. If you need assistance, please search for your insurance company below.
  2. Follow the instructions on that website on how to file an appeal. We recommend you include the following information:
    • Patient Name
    • Insurance Carrier
    • Member ID
    • Group Number
    • Original Physical Issue/Complaint/Symptoms
    • Physician Specialty visited i.e., Urology, PCP, Ortho etc.
    • Name of Provider/Practice and location
    • Diagnostic Method utilized/ordered by provider. i.e., culture, PCR.
    • The MicroGenDX test is covered by Medicare through the PLA code 0112U. The PLA code has the following description: “Infectious agent detection and identification, targeted sequence analysis (16s and 18s rRNA genes) with drug-resistance gene.” Even if you have non-Medicare insurance it can be helpful to share this with your provider.
  3. If you write a letter, it may also be helpful to include the following elements in your response:
    • What are/were your symptoms? For how long did you have them?
    • What was the diagnosis?
    • If you had previous treatments that failed. If so, how many?
    • Have you had testing prior to MicroGenDX? If so, what was it? Did it find anything?
    • How did the successful diagnosis and treatment affect your life? Confidence in your provider?  Emotional well-being? Etc.
    • If you have already had a culture test and it wasn’t successful.
    • That you have already had a round of antibiotic treatment and it was not successful.
  4. If you send your insurance company a letter, we also suggest that you call them as a follow-up.

Is the MicroGenDX Test Covered by Medicare and Medicare advantage?

Medicare, America’s largest health insurance provider, recognizes the importance of MicroGenDX testing and offers coverage under its PLA code. While most Advantage plans honor this provision, it is possible that some of the available Medicare Advantage plans might not follow this guidance.

What should I do if my insurance does not respond a request for coverage for the MicroGenDX test?

If your insurance provider doesn't accept your request for coverage, MicroGenDX is here to help. We offer discounted tests at just $249 and are more than happy to reimburse you, as appropriate, if successful upon submission of an appeal!

List of Insurance Contacts

Aetna Medicare Plan
Aetna Medicare Plan customer service number and request coverage. 1-800-282-5366 7 days a week, 8 AM to 8 PM
Allwell Medicare Advantage
Visit this website and download the form and follow the instructions on the website to mail in the completed form
The procedures for filing a Complaint/Grievance or Appeal are outlined in the Ambetter member’s Evidence of Coverage or by calling Ambetter at 1-877-687-1197.
BCBS Federal
Call the customer service telephone number on the back of your FEP Blue Focus ID card, or send your request to us at the address shown on your explanation of benefits (EOB) form for the Local Plan that processed the claim.
BCBS Of California
Call Blue Shield Promise Cal MediConnect Plan Customer Care: Phone:(855) 905-3825, 8 a.m. – 8 p.m., seven days a week.
BCBS Of California Anthem
Mail your written appeal to: Anthem Blue Cross Cal MediConnect Plan MMP Complaints, Appeals and Grievances 4361 Irwin Simpson Road Mailstop OH0205-A537 Mason, OH 45040 -OR- Call Member Services at 1-855-817-5785 Monday through Friday from 8 a.m. to 8 p.m.
BCBS Of Georgia Anthem
Visit this website and download the form and follow the instructions on the website to mail in the completed form
BCBS of Kansas City Health Insurance Plan
Call the BCBSKS Customer Service Center: 1-800-432-3990 or 1-785-291-4180
BCBS of Louisiana Health Insurance Plan
Visit the and download their written request appeal form and mail it to Blue Cross and Blue Shield of Louisiana - Customer Service Unit Appeals and Grievance Coordinator P. O. Box 98045 Baton Rouge, LA 70898-9045
BCBS of Maryland CareFirst Health Insurance Plan
Call member services 1-410-779-9369 or 1-800-730-8530 to get an appeal form. Or visit the website and download it.
BCBS Of Massachusetts
Visit this website and download the form and follow the instructions on the website to mail in the completed form
BCBS of Missouri Anthem Health Insurance Plan
Contact via the webchat
BCBS of North Carolina Health Insurance Plan
See the appeals process in your Member Guide. -OR- Call 1-888-206-4697
BCBS Of NY Empire
Call the appropriate number for your plan: Empire MediBlue Dual Advantage (HMO D-SNP) 1-877-269-5706 Empire MediBlue Dual Advantage Select (HMO D-SNP) 1-844-469-1762 Empire MediBlue Plus (HMO), Empire MediBlue Core (HMO), Empire MediBlue Choice (HMO-POS), Empire MediBlue Select (HMO), Empire MediBlue Core Select (HMO), Empire MediBlue Extra (HMO) 1-800-499-9554 Empire MediBlue Access (PPO) 1-866-395-5175
BCBS of Pennsylvania Highmark Health Insurance Plan
Log into your Highmark member portal account and contact Highmark via Message Center. If you do not have a member portal account, you can either register on the website or contact customer service at the number on the back of your ID card. -or- Call 1-800-241-5704, 8 a.m. - 6 p.m. EST
Superior Health Plans
Call one of the following numbers based on your plan STAR/CHIP 1-800-783-5386 STAR Health 1-866-912-6283 STAR+PLUS 1-877-277-9772 STAR Kids 1-844-590-4883
Tricare West
Visit this website and download the form and follow the instructions on the website
Fill out this form and mail to UMR – Claim Appeals PO Box 30546 Salt Lake City, UT 84130 – 0546
Wellmed Medical Management
Log into your WellMed Account and fill out an appeal of Coverage form -or- Visit this website

Don’t see your insurance provider?

On a web browser search “[Insurance Company Name] appeal insurance coverage” Most companies will have a page detailing what steps you should take to ask for coverage.

If you would like additional contacts for these providers please reach out to us at: (855) 208-0019, extension 2002 Hours: M-F 8am–8pm EST, Saturday 9am–6pm EST 

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