Thursday, December 10, 2009

Not Medically Necessary



After a courageous 5-year battle, R lost his fight with cancer. He lived a good life while he was being treated, finishing high school, starting college, and checking items off his bucket list. This holiday season is hard for his family. His absence is palpable … and painful. What could make this time any worse?


The letter they got from their insurance company.

Apparently I ordered a CT scan back in September. The insurance company sent the family a letter telling them that they have deemed the scan “not medically necessary,” and they are refusing to cover it.

I’m used to the things health insurance companies do to try to avoid “medical losses” (their term for payments made to health care providers). I often have to fight with them when they don’t want to cover treatment that is part of a clinical trial (even when the trial is standard of care), or when they don’t approve of my choice of antibiotic, or don’t want to pay for a bone marrow transplant. Those denials, however, are usually couched in terms like “this is not a covered benefit.” This allows the company to claim that they are not making medical decisions : they are making a determination of what is covered – it is up to the physician and patient to decide what treatment is necessary, they are only deciding whether they will pay for it based on the terms of the policy.

This letter is different. It is denying coverage because someone decided the scan was “not medically necessary.” That person has made a medical decision.

Who is the person that made this decision? There is no way for me to find out, but it is likely that the person making that decision is not a pediatric oncologist with experience taking care of kids with multiply relapsed, refractory osteosarcoma. The person who made this determination may not be a physician at all. I am certain of one thing, however. This person was not in the room examining my patient when I decided he needed a CT scan. This person was not responsible for the health of my patient. This person was not trying to decide if a treatment was working, and if not, what we should do next. This person was not helping to treat my patient in any way.

What kind of penalty would I face if I were making medical decisions for patients who I did not see, talk to, or examine … whose cases I was not familiar with? Apparently, there is no penalty for someone making medical decisions from the comfort of their corporate office building, looking at nothing more than the interval of time between two scans.

Yes, I will appeal the denial. Hopefully the insurance company will agree to cover the bill. But only Ebeneezer Scrooge would think it reasonable, during the holiday season, to mail such a letter to the parents of a child who just passed away. Only the Grinch, whose heart was two sizes too small, would think it reasonable for someone in an office building to look over my shoulder and decide that a CT scan I ordered to evaluate the progress of my dying patient’s cancer was “not medically necessary.”



 
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13 comments:

Anonymous said...

Oh, you go, Dr. David, you go!! I could feel your passion for your patients in this blog, and I admire you so much for this. In reading your words, I knew exactly what the next word would be, as,a mother who has a child with cancer, I have repeated these exact words in my own thoughts and musings so often. And my child has labeled all insurance companies as "The evil ones", since we have had to fight them for his very survival so many times. I firmly believe that all insurance reviewers should have an enforced job qualification of being touched personally by someone close to them, if not themselves,with a serious, life threatening illness. Oh well, in a perfect world...... Thank you for being such a caring and compassionate doctor.

Karen Lee, Mother of Keaton www.caringbridge.org/visit/keatonlee

Ravonda said...

Well argued and uplifting. Getting a little 'riled up' on behalf of your patient and his family made my heart smile.

Ravonda

Elizabeth Munroz said...

I have often thought that insurance companies should be required to provide the name and status of the person making the medical decision. Wish there was legislation that would institute this.

Morah Mary said...

Go for it, David. I, too, am tired of insurance companies deciding that my daughter's prescription can't be filled because "it's too soon" or "the other prescription we just filled should be working."

And when I ask the pharmacist who has given the insurance companies the right to diagnose and treat, I get a blank stare. I know it's not their fault, but the pharmacist is there - and the insurance company is not. ]

Please accept my condolences on the death of your patient. I hope his family eventually finds comfort in their memories.

Anonymous said...

My friend in college was one of these health insurance company gophers. Yes, meaning he only had a high school diploma, and used a binder with directions on which page to turn to depending on how the physician answered questions. Like a "choose your own adventure" novel, eventually you find a decision. If only finding cures were that simple...

Anonymous said...

While I agree that medical costs need to be contained,I believe the insurance companies are all too often denying legitimate expenses.

Recently we were left with a $6k bill because of the materials the surgeon decided to use during a procedure on my wife were not approved. It was deemed experimental and not medically necessary. We were not informed of this going into the procedure.

As we have pursued this, what is remarkable is that we are pretty much on our own. Our surgeon wrote a letter that did not help and our appeal has been denied. What I am interested in finding is an advocacy group or even a lawyer that deals with this situation. There is certainly a need.

In the situation of you patient, not only was it the wrong decision, it was in extremely poor taste.

Doctor David said...

Thanks for the comments, everyone. As follow-up, I was at least able to make arrangements so the family is no longer being billed for the scan in question. Of course, while that is a happy ending for them, it does nothing to change the underlying problem.

Maybe one day, things will change.

Anonymous said...

Curious as to where this case is at now!?

Viagra Online said...

How sad hi was an incredible artist and a great father, I didn't deserve to die this way...

Pretty in Pink Photography said...

I stumbled upon your blog while googling "not medically necessary" or something to that effect.
You sound like such a caring doctor and I admire that especially from a standpoint of being a mom of two sickly/special needs children.

We were just denied a peer to peer appeal & member appeal for a lumbar MRI in prone/supine view to rule out tethered cord. It wasn't "medically necessary." I hope the neurosurgeon who denied it sleeps well at night, knowing her scan came back positive for tethered cord. She's already falling upwards of 25 times per day, has had urinary retention since January & is having trouble with bowel movements now.

It makes me SO IRATE that those doctors' can't be held accountable for the fact that they could have been solely responsible for causing my daughter irreversible neurological damage up to & including losing use of her legs!!

Krystle said...

I stumbled upon your blog while googling "not medically necessary" or something to that effect.
You sound like such a caring doctor and I admire that especially from a standpoint of being a mom of two sickly/special needs children.

We were just denied a peer to peer appeal & member appeal for a lumbar MRI in prone/supine view to rule out tethered cord. It wasn't "medically necessary." I hope the neurosurgeon who denied it sleeps well at night, knowing her scan came back positive for tethered cord. She's already falling upwards of 25 times per day, has had urinary retention since January & is having trouble with bowel movements now.

It makes me SO IRATE that those doctors' can't be held accountable for the fact that they could have been solely responsible for causing my daughter irreversible neurological damage up to & including losing use of her legs!!

Krystle said...

I stumbled upon your blog while googling "not medically necessary" or something to that effect.
You sound like such a caring doctor and I admire that especially from a standpoint of being a mom of two sickly/special needs children.

We were just denied a peer to peer appeal & member appeal for a lumbar MRI in prone/supine view to rule out tethered cord. It wasn't "medically necessary." I hope the neurosurgeon who denied it sleeps well at night, knowing her scan came back positive for tethered cord. She's already falling upwards of 25 times per day, has had urinary retention since January & is having trouble with bowel movements now.

It makes me SO IRATE that those doctors' can't be held accountable for the fact that they could have been solely responsible for causing my daughter irreversible neurological damage up to & including losing use of her legs!!

viagra online said...

Pour R, he was an awesome person, there's no doubt about it! we gonna miss his jokes so much!