Claims denied: A Blue Cross story of insurance and cancer

Filed Under: Costs, Health plans, Patients

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Summary: Stories of claims denied are common in the health care industry. This one, about a man ordered to go immediately to the hospital for life-saving treatment, whose claim was then denied, got a lot of coverage because it was so startling. His wife, Zoe Keating, wrote this blog post

“On May 13 an MRI found 20 tumors in my husband’s brain. On May 15 he could barely breathe and was in a lot of pain. A CT scan that day revealed he had a softball-sized tumor in his lung, tumors in his other lung, his liver and possibly his bones. On our way home from the imaging center our primary care doc called and told us to turn around and get to the hospital right away. My husband was admitted and they promptly removed more than a pint of fluid from his lungs, which helped him breathe better. We were there for 6 days while they performed a bronchoscopy, did more scans, gave him drugs to stop his brain from swelling and administered emergency chemo.

“Today I got a letter from Anthem Blue Cross regarding his hospital stay:

” ‘Coverage for the requested service is denied because the service does not meet the criteria for ‘medical necessity’ under your description of benefits. To assist our Medical Director in making this decision, we have put a process in place to send all information about the service to a clinical reviewer with appropriate credentials. Based on their opinion, we have determined that coverage for the requested service is denied. Our Medical Reviewer Layma Jarjour MD has determined we cannot approve your hospital stay for cancer. We do not have enough facts to show that it was medically necessary.’  ” via As if this isn’t hard enough | Zoë Keating.