Here are questions people in Los Angeles ask when they face health insurance cancer treatment denials due to lack of medical necessity. Such insurance cancer treatment denials can mean the difference between life and death. A delay of such treatment can reduce the amount of time one has left to live. If a health insurer sends you a cancer treatment denial due to medical necessity despite your oncologist’s opinion, we can help. The answers below hopefully provide you with the information you need to fight or avoid a denial. These answers can also help you avoid a medical necessity denial if you are afraid that your insurer will issue such a denial in the future. If you do not see your insurance cancer treatment denials questions here, please contact our office and we will provide you with an answer.
What is “Medical Necessity?”
There is often a disconnect between the colloquial meaning of words and how health insurers use them in insurance policies. It is reasonable to believe a particular treatment is medically necessary if an experienced oncologist deems it best. The case is even stronger if the oncologist is from a preeminent cancer institution. Preeminent cancer institutions include those like City of Hope, USC Norris, Loma Linda and Children’s Hospital of Los Angeles. However, health insurers still deny coverage in such circumstances. Health insurers may deny such treatments as not “medically necessary” based upon their own definitions of the term.
Each health insurance policy contains its own specific definition of medical necessity. For this reason, it is important to look in your own health policy to see what definition is used. Generally, many health policies state treatments are “medically necessary” if they are safe and effective to treat a particular condition for which a doctor is prescribing it. That said, health insurers rely upon different specific standards and criteria when determining whether particular treatments are actually medically necessary.
How do insurance companies like Anthem Blue Cross or Blue Shield of California determine if treatment is medically necessary?
Private insurers such as Anthem Blue Cross or Blue Shield of California rely on their own clinical guidelines. Such policies can include criteria that is overly restrictive. Policies may exclude treatments in circumstances that the community of oncologists recognize to be safe and effective. California law forbids health insurers from using policies that vary from the standard of care of treating oncologists. If a health insurer’s clinical policy is overly restrictive in its definition of medical necessity, it is often worth fighting to get coverage.
Government health insurance policies like Medicare or Medicaid (Medi-Cal in California) often utilize national guidelines from third party organizations. In the context of cancer, the government often relies upon the criteria in the National Comprehensive Cancer Network (“NCCN”) guidelines. Private insurers like Blue Cross of California and Anthem Blue Cross sometimes also look to these guidelines but more often just create their own.
Why did my insurance company deny my treatment as not medically necessary?
The less money an insurance company pays for your treatments, the more profit it makes. All insurance policies include a coverage exclusion which limits coverage for treatments that are not medically necessary. There are multiple reasons an insurer can deem a cancer treatment not medically necessary when such treatment is actually necessary.
Overly Restrictive Criteria and Guideline
One reason an insurance company can use and rely upon is an overly restrictive criteria and guideline as discussed above. An insurance company can use improper criteria because they rely on out-of-date articles. They can also put too heavy an emphasis on published literature instead of looking to the actual standard of care that practicing oncologists use. They might also ignore controlled trial data until it is published. The insurance companies may rely on individuals who do not understand the particular treatment to create the criteria. Another reason can be that the policy creation is dictated by business concerns directly. For example, an insurance company might intentionally and directly create an overly restrictive policy because the treatment is expensive.
Reliance on an Unqualified Reviewer
Another reason for an improper denial of cancer treatment coverage due to medical necessity can be reliance upon an unqualified reviewer. If the reviewer has no understanding of the medicine involved, then they can misapply the criteria and result in an improper denial. A reviewer can be unqualified if they do not understand the area of medicine. For example, if an insurer uses an internal medicine doctor with no cancer experience to decide whether chemotherapy is appropriate and medically necessary, that doctor might deny coverage improperly. A denial would be even more likely if the insurer simply uses a nurse or pharmacist to conduct such a review.
A reviewer can also be unqualified if the insurer has not properly trained them to conduct a thorough investigation. California law requires insurance companies to conduct full, fair, and thorough investigations into the grounds for coverage before denying care. This includes an obligation to look for reasons to support coverage and not just sit back and deny if they lack the information to approve. If an insurer does not train its reviewers to conduct necessary investigations, then the result can be improper medical necessity denials even if the reviewer understands the medicine involved. For example, a patient goes to City of Hope and his oncologist sends a request for a specific medication but does not send medical records illustrating the patient’s particular diagnosis. Here, the insurance company needs to have trained its reviewer to contact City of Hope to ask about the diagnosis before denying coverage for the medication.
Financial Incentive to Deny Care
Another reason can be when an insurance company provides a financial incentive to the reviewer to deny care. For example, there may be a bonus system tied to corporate profits. Here, a reviewer might deny coverage solely because they know it will mean bigger profits and therefore a bigger bonus. In this case, the reviewer puts his or her own interests ahead of the insureds.
A final reason for medical necessity denials of cancer treatments is simply that the denial is a mistake. People make mistakes. Papers can be lost. The reviewer can miss something in the records that a doctor sent in for their patient. Perhaps there is a similar type of accident which results in a denial. Mistakes can cause stress and harm to a person who is unable to get timely access to care.
Should I appeal insurance cancer treatment denials based on medical necessity?
Whether or not to appeal a denial depends upon your specific circumstance and situation. One of the biggest considerations in determining whether to appeal is whether you have an “ERISA” policy. The Employment Retirement Income Security Act of 1974 (ERISA) is a federal law. ERISA sets parameters and restrictions on certain types of health plans. Generally, ERISA governs most health plans and insurance policies that employers provide to their employees. ERISA does not govern most individual and family health plans and insurance policies that you can buy on Covered California’s exchange or directly from health insurers like Anthem Blue Cross or Blue Shield of California.
ERISA Health Plan
If you have an ERISA health plan or insurance policy, then it is extremely important that you file an appeal. Why? If you do not appeal, then you will have no other options for challenging an improper denial under ERISA. In other words, if you do not appeal the denial to the insurance company, then you will not later have the option of seeking help from a judge to overturn the denial. What you include in the appeal for an ERISA policy is very important and you should consult with an attorney specialized in such appeals to help guide you before making the appeal. We are happy to assist in any way that we can if you are in such a circumstance.
Non-ERISA Health Plan
If ERISA does not govern your health plan, then there are a number of things to consider before appealing. These considerations can include the specific basis for the denial. For example, if the insurance company claimed a treatment was not medically necessary because it lacked information that you have available, then it could be worth filing an appeal to send in such documentation. Another consideration is whether the denial has caused physical, emotional, and/or economic injury. Here, instead of filing an appeal, you might want to file a lawsuit because it would be the only way to recover money for such injuries. If you have a question about your particular case, please contact us and we will help in any way we can.
What are different types of appeals for denial of treatment based on medical necessity?
There are numerous types of appeals available when an insurance company denies cancer treatment for a lack of medical necessity. One type is called a “peer to peer” appeal. This is where your doctor calls up and talks to another medical professional who works for the insurance company to discuss the denial. The insurance representative is supposed to be a “peer” and therefore have the appropriate experience and education to understand the condition and treatment at issue. Unfortunately, this is often not the case. In such circumstances, peer to peer appeals are unlikely to lead to any change by the insurance company of its determination. If your doctor is willing to spend the time to conduct a peer to peer appeal, it is usually worth it as there is little downside.
Another type of appeal is one that you or doctor can make directly to the insurance company. Here, you or your doctor can call and request an appeal. Alternatively, you or your doctor can send in a letter and documents to support an appeal. You also often have the option of submitting a request for an Independent Medical Review (IMR) from the California Department of Managed Healthcare (DMHC). You can only request an IMR if you have a denial based on medical necessity. For an IMR, the DMHC sends your case to a third-party company that uses its doctors to review the denial. There are serious issues to consider before proceeding with an IMR. It is best to discuss these issues with an attorney in our office before making the decision to do so.
Lawsuit: Aetna Denied Coverage for Chemotherapy For Elderly Los Angeles Woman Fighting Colon Cancer, Law Offices of Scott Glovsky Lawsuit Alleges
September 24, 2018 – Scott Glovsky of The Law Offices of Scott Glovsky filed a lawsuit in Riverside Superior Court on behalf of Rosalie Vaccarino against Aetna, Inc. and Aetna Health of California, Inc. for bad faith and breach of contract.
Rosalie Vaccarino is a seventy-eight year old woman suffering from colon cancer. She was diagnosed in or about August of 2017 and at the time she a health maintenance organization (“HMO”) health plan provided by defendant Aetna Health of California, Inc. (“Aetna”). In September of 2017, Rosalie had surgery to remove cancerous tumors and her oncologist then prescribed chemotherapy to begin as soon as possible.
Despite Aetna’s legal and contractual obligation to provide coverage for medically necessary services and treatments, when Rosalie and her doctors sought coverage for chemotherapy, Aetna denied numerous requests from November of 2017 through February of 2018 asserting each time that the treatment is not medically necessary. In March of 2018, Rosalie was forced to switch to a Preferred Provider Organization (“PPO”) health plan that Aetna offered and when her provider submitted a request for chemotherapy to the new Aetna health plan, it was approved as medically necessary.
Unfortunately, the delay allowed new cancerous tumors to rapidly grow and caused severe physical injury.
This case is Vaccarino v. Aetna, Inc., et al., Riverside Superior Court Case No. RIC1819360.
Attorneys Ready to Help You Now
If you or loved ones receive health insurance cancer treatment denials, the Law Offices of Scott Glovsky specializes in insurance law and is here to help.