![]() ![]() One of those was out of date: It cited guidelines by a professional society of radiation oncologists that had subsequently been updated to support proton therapy for head and neck cancers.įuller noted that AIM had “glaringly omitted” information from the National Comprehensive Cancer Network, an alliance of cancer treatment centers that included M.D. Fuller found only a few that pertained to head and neck cancer. The Medical Review Institute did not return requests for comment.īut prior court rulings had carved out an exception: If Corkern could prove that Blue Cross had committed an “abuse of discretion” - for instance, if it had blatantly ignored or twisted evidence supporting the therapy - the judge could force the insurer to pay Salim for his treatment.Ī nine-page letter written by Fuller, Salim’s doctor, argued that very thing, criticizing the guidelines that AIM and Blue Cross had relied upon to deny payment.ĪIM had cited 48 research studies to support its rejection of proton therapy. Its doctor, a radiation oncologist, not only quoted AIM’s guidelines, but also cited four studies that raised questions about the evidence for proton therapy. The next day, the Medical Review Institute denied the claim. Louisiana’s Department of Insurance randomly selected the review company, Medical Review Institute of America.įuller didn’t skimp on evidence: He sent the company a 225-page request containing Salim’s medical records, MD Anderson’s evaluation and outside studies supporting the use of proton therapy. Not willing to give up, Fuller, Salim’s doctor, took a step physicians rarely do: He asked Blue Cross to have an independent medical review board unaffiliated with the insurer or AIM examine Salim’s claim. AllMed did not return requests for comment. He, too, copied AIM’s guidelines in explaining his reasons. A day later, AllMed’s doctor, a radiation oncologist, affirmed the decision to deny payment for Salim’s care. ![]() The insurer then routed Salim’s request to an outside company called AllMed that it had hired to render expert opinions. ![]() He affirmed the denial using language taken directly from AIM’s guidelines. In a statement, Elevance said that Carelon “uses evidence-based clinical guidelines to assess requests.”Īt Blue Cross, Salim’s appeal started with a review by one of its own doctors: an ear, nose and throat specialist. AIM’s parent company, Anthem, renamed itself Elevance Health in 2022, and subsequently changed AIM’s name to Carelon Medical Benefits Management. ![]() In Salim’s case, AIM made decisions using its own guidelines, which it said at the time were based on medical studies and the recommendations of professional medical associations. Critics say the companies unfairly deny claims, noting they market themselves to insurers by promising to slash costs. The insurance industry maintains such companies keep health care costs down and help patients by rejecting unnecessary and unproven treatments. Blue Cross and other health plans often farm out those reviews to companies like AIM. Many insurers won’t pay for certain specialized or expensive treatments unless a patient gets approval in advance. They cut and pasted guidelines created by a company called AIM Specialty Health: “The requested proton beam therapy is not medically necessary for this patient,” one rejection letter read. But the insurance industry doctors who shot down Salim’s appeal did little to consult outside sources, a ProPublica review found. ![]()
0 Comments
Leave a Reply. |
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |