Former Police Captain Continues to Fight Anthem Blue Cross Denial for Medically Necessary Back Surgery

Blog, Insurance and Healthcare Denials, Insurance Bad Faith
Former Police Captain Continues to Fight Anthem Blue Cross Denial for Medically Necessary Back Surgery

Retired Los Angeles Police Department Captain, Joel Justice, filed a lawsuit against Anthem Blue Cross. Joel Justice is fighting the Anthem Blue Cross denial for coverage for a spinal decompression and fusion surgery that Joel’s neurosurgeon, Dr. Igor Fineman, deemed medically necessary. The case is Justice v. Blue Cross of California dba Anthem Blue Cross, Los Angeles Superior Court Case No. BC709255.

Spinal Decompression and Fusion Surgery Necessary for Stenosis

Living with severe back pain since he was a teenager, Joel’s pain became particularly severe in 2016. Joel visited Dr. Fineman for relief. Joel tried conservative treatments over the years such as epidural injections, stretching, chiropractic and physical therapy. While these treatments provided some level of relief, the pain always came back. On bad days, the pain was excruciating and prevented Joel from basic activities. After getting and reviewing MRIs of Joel’s spine, Dr. Fineman diagnosed Joel with stenosis. Dr. Fineman prescribed epidural blocks to see what relief they could provide before resorting to surgery. Joel received a series of additional epidural injections, yet the pain always returned. In addition, the injections grew less and less effective. Only then did Dr. Fineman determine that surgery was necessary. He deemed a single level decompression and spinal fusion surgery necessary to address Joel’s stenosis.

Anthem Blue Cross Denial of Medically Necessary Surgery

Dr. Fineman scheduled the surgery for May 31, 2018. He sent in an authorization request to Joel’s health insurer, Anthem Blue Cross, on May 18, 2018. Anthem sent the request to its reviewer Dr. Ralph Watson. Dr. Watson is a reviewer who had not practiced medicine for more than 25 years. This reviewer also had no experience with back surgeries. Anthem sent a denial letter with Dr. Watson’s signature on the same day as the request. Despite Dr. Fineman’s determination, Dr. Watson denied coverage for the surgery because Anthem didn’t consider it medically necessary.

A few days later, Dr. Fineman sent Anthem an additional fifty-two pages of medical records and again requested coverage. Anthem again sent this case back to Dr. Watson who the following day sent another denial letter. The denial letter indicated that Anthem again determined that the surgery was not medically necessary. Upon receiving this letter, Dr. Fineman called a phone number on the denial letter to try to speak with Dr. Watson. Anthem did not provide Dr. Watson. Instead, Anthem had Dr. Fineman speak with another doctor. Dr. Fineman explained to this doctor the surgery, the indications for it, and Joel’s history of unsuccessful treatments. Anthem still refused to cover the surgery and sent another denial letter on May 30, 2018.

Joel has been unable to get surgery and the Law Offices of Scott Glovsky filed a lawsuit on his behalf. Anthem continues to oppose the lawsuit vigorously and to date has continued its refusal to provide the surgery. Even though Joel has paid his monthly premiums to Anthem throughout this time, he continues to live in pain. Our firm will continue to fight for Joel until he is finally able to have his day in court in front of a jury.

The Law Offices of Scott Glovsky specializes in insurance bad faith, catastrophic personal injury & health-related litigation. Scott Glovsky started the firm to help ordinary people suffering because of negligent and bad acts of organizations and corporations.

If you have an issue with your insurance company, please contact us and we can help.