Do you ever wonder whether some insurers may simply have chosen the wrong line of work? The basic exchange in health insurance entails receiving money from people who want their healthcare needs covered, and then using some of that money to cover those needs when they arise. It seems like most insurers are pretty comfortable with the first part. It’s that second part that’s proving to be tricky for some of them.
Modern Healthcare’s story touches on this incongruity, as exemplified by health insurance heavyweight, Aetna. Aetna is denying claims for lumbar ADR, a type of spinal surgery that the insurer has described as “experimental” and “investigational.” However, a class action suit involving more than 200 patients contends that Aetna has been breaking the law with these denials. They’re suing Aetna based on rules outlined in the Employee Retirement Income Security Act, which sets standards that private health plans have to follow. The suit’s two main plaintiffs sought the surgery on the basis of their doctors’ recommendations, after corrective exercises and medication weren’t successful.
Modern Healthcare reports that Aetna didn’t provide a comment on the lawsuit to them, so it’s hard to know just how the insurer justified the denials. The article cites a 2018 Journal of Orthopaedic Surgery and Research report, which found that lumbar ADR’s clinical success rate is actually 53.7% to 71.4%. Add the fact that the satisfaction rate in patients who undergo the procedure was 75.5% to 93.3% and it gets harder to see why they consider it “experimental.” But wait—there’s one last statistic: lumbar ADR costs range from $30,000 to $100,000. Suddenly, we have fewer questions regarding Aetna’s reluctance to approve it.
We see this as another example of an insurer wedging itself into the physician/patient relationship, with pretty transparent motives. For example, cancer survivors were denied coverage for their proton beam radiation therapy by UnitedHealthcare, resulting in a potential class-action suit. In both instances, this strikes us as deeply inappropriate, especially because the treatments were recommended by their doctors.
