Submission of peer-reviewed literature can strengthen medical necessity and experimental/investigational appeals. Insurance companies have a duty to review information submitted during an appeal. Furthermore, an insurance company’s failure to properly review the clinical information can jeopardize their ability to legally defend their denial decision.
In litigation involving a Prudential medical necessity denial, an attorney submitted 25 peer reviewed articles supporting physical therapy for the treatment of multiple sclerosis. The court noted that the information was not specifically responded to and that no one attempted to contact the ordering physician to review the matter. “Our odyssey through this record makes clear Prudential never evaluated Ms. McGraw’s individual case but rubber stamped the “nature of her condition and denied each subsequent claim arising from her MS,” the court finding states. See the decision at www.oscn.net/applications/oscn/DeliverDocument.asp?CiteID=150591.
In Hughes v. Blue Cross of Northern California, 263 Cal. Rptr. 850, the patient was admitted for inpatient treatment of a mental disorder after several attempts at outpatient treatment had failed to produce desired results. The insurer denied the coverage for the treatment and indicated care should have continued at a lower level. The insurer’s denial, however, did not outline specific medical reasons to support the decision. The lower court ruled that the insurer breached its covenant of good faith and fair dealing by employing a standard of medical necessity significantly at variance with community standards and by failing to properly investigate all records pertinent to the insured’s claim. The court stated: By not identifying the records on which the consultant’s recommendation was based, the letters tended to assure that the staff’s earlier failure to secure all relevant records would go undetected. And by omitting any explanation of the medical grounds for the intended denial of coverage, the letters placed an undue burden of inquiry on the insured’s physician. The Blue Cross witnesses, in fact, defended the letters on the grounds that the physician was free to write or call the medical review department to gain more information. The covenant of good faith and fair dealing, however, placed the burden on the insurer to seek information relevant to the claim. This requires that the necessary letter to a treating physician be drafted in a manner to elicit an informed response.
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