Patient Denied Coverage for 2nd Reconstruction

This month, we offer an example of persistence by the patient and her family resulting in a reversal of coverage denial. Even the most reliable insurers make mistakes and need to be alerted to them. Insurance employees without the proper training and credentials may make inappropriate decisions regarding the coverage of medically necessary care.

You and your clinical team can help patients and their families recognize these situations and provide them with guidance to successfully overcome such barriers. Your ability to make a positive impact goes well beyond the provision of medical care.

Virginia, a 51-year-old law librarian, was married with three children in college when she was diagnosed with early stage breast cancer. Her oncologist initially believed she could be adequately treated with a lumpectomy. However, she had an extensive family history of breast cancer, and after being informed of this, her insurance carrier agreed to cover a bilateral mastectomy, followed by breast reconstruction with saline implants.

The reconstructive surgery was performed at Virginia's local community hospital by a surgeon with no training in this aspect of breast cancer follow-up care. The result was unsuccessful, leaving her with a misshapen and asymmetrical reconstruction. This surgeon eventually lost his license due to misrepresentations related to his medical training.

Devastated, Virginia opted for a second reconstructive surgery during which a plastic surgeon corrected the serious asymmetry created in the initial surgery. The surgeon replaced the saline implants with silicone implants. Virginia's insurer had approved all her cancer treatment and the initial reconstruction, but denied the secondary corrective surgery as "not intended to correct a functional problem" and therefore as being essentially "cosmetic."

Appeal Strategy

Virginia's oldest daughter, Alyssa, in her last year of college, had become a volunteer for a breast cancer support organization in her college community. The group provided support to her mom in pursuing her appeals within her insurer's appeals structure. When all of the internal appeals were exhausted, Alyssa contacted the Medical Care Ombudsman Volunteer Program (MCOP).

MCOP quickly assembled a panel consisting of medical oncologists, surgical oncologists, and plastic and reconstructive surgery experts. The panel was understandably shocked by the coverage denial of the secondary surgery given the patient's history.

With some persistence, the MCOP medical oncologist worked his way up the insurer "command structure," finally reaching the divisional medical director. This divisional director, it turns out, was "concerned" that a claims person had applied the guidelines by the numbers without any thoughtful consideration of the patient's situation.

The insurer's medical director, however, balked at a reversal of the denial, explaining that he felt his hands were tied because the internal appeals were exhausted and no further remedy lay within the insurer's appeals structure.

The medical oncologist expert, in consultation with MCOP, decided that the medical review panel would put together a strong written opinion supporting payment for the second reconstruction, and the MCOP program directors would contact the insurer's legal department to determine what steps were necessary to allow for coverage of the procedure and to avoid litigation.

The review panel provided a written opinion to MCOP documenting that Virginia's treatment, which included surgery, chemotherapy and radiotherapy, also mandated reconstructive surgery, which was considered necessary to restore the patient to as normal a status as could be achieved. The secondary reconstructive procedure or "revision" procedure was performed to improve the patient's appearance, but only because the original reconstructive surgery had been "botched." Therefore the revision was essential to achieve this goal of returning her to a normal state and under these circumstances should be approved by the insurer.

The insurer's guidelines, and indeed the statutory structure of provisions that applied, are designed for the goal of successful reconstruction. The review panel correctly concluded that the denial was at variance with the standard of care for breast cancer patients with this profile.

Armed with this consensus opinion, MCOP contacted the insurer's corporate legal office. After some discussion, the insurer's counsel stated that the insurer would not open a file on this case until they received a letter from Virginia's "counsel" indicating that the next step would be filing a suit citing arbitrary and capricious application of corporate/insurance guidelines. An MCOP volunteer lawyer provided the letter to the insurer's counsel and attached the consensus opinion. The insurer's corporate legal office arranged for complete coverage of the procedure and ancillary hospital care. The claims person who applied the guidelines incorrectly in this case was remanded for additional training.

The insurer then decided to put a tickler in its claims system that would flag any cases concerning reconstruction of any kind for cancer patients. The new rule also required that nursing personnel review such cases and that any potential denials of such coverage would require review by the insurer's medical director.

Alyssa wrote up her mother's case for the support group file to offer guidance for others faced with a similar situation. She also wrote a letter to the editor of the local paper to raise awareness of the issue and potential pitfalls for cancer patients requiring reconstructive surgery. She applauded the insurer for its sensitivity in dealing with this case and for adopting a process that would mitigate similar situations in the future.

Lesson Learned

• Even the most conscientious insurer can make a serious mistake if claims administrators are careless.

• Volunteers for a patient advocacy organization can be an excellent hands-on resource and should always make sure that they have access to medical and legal volunteer assistance when necessary to unravel complicated treatment and payment issues.

• A health plan's legal department more often than not will grasp the issues that drive litigation exposure. Remember, these legal departments exist in part to minimize risks to their company and avoid adverse publicity.