So, let’s say a woman you know is diagnosed with breast cancer, and with the right healthcare, she beats it. It’s a tough fight, but she beats it. Everybody breathes a sigh of relief. Only she’s not done fighting yet—her next battle is with her health insurance company.
That’s essentially the story behind a lawsuit filed by a pair of physicians, on behalf of their patients, contending that United is shirking its responsibility to cover post-mastectomy surgery. In particular, it’s not covering deep inferior epigastric perforator (DIEP) flap breast reconstruction surgery. United’s denials cite a lack of medical necessity, while the lawsuit alleges that United is “in violation of the Employee Retirement Income Security Act (ERISA) by not uniformly covering the post-mastectomy surgery.”
What’s behind the insurer’s heel-dragging? It looks to us like they are cutting corners at the staffing level. In its blanket policy on breast reconstruction surgeries, the United rule prohibits post-mastectomy procedures done by more than one surgeon. In their formal complaint, the plaintiffs note that United policy is to deny coverage to patients whose surgeons perform this procedure “as either assistant surgeons or as co-surgeons, based on United’s blanket determination that multiple surgeons are not ‘medically necessary’ to safely perform the procedure.”
The plaintiffs point out that this policy flies in the face of standard industry practices, as well as “the overwhelming balance of medical literature, which indicates that all breast reconstruction microsurgery should be performed by two surgeons.”
Of course, United is no stranger to complaints from its members about denying their claims. In March, we covered the story of the suit brought against the insurer by cancer patients seeking reimbursement for a treatment that’s covered by both Medicare and Medicaid, which was approved by the U.S. Food and Drug Administration more than 30 years ago, but which United insisted was “experimental.”
The law regarding ERISA is pretty clear: Once an ERISA plan provides coverage for a mastectomy, coverage is required to be provided for breast reconstruction “in a manner determined in consultation with the attending physician and the patient.” So, even if United feels like two’s a crowd, it looks as though they’re running afoul of the law when they refuse to reimburse for two-person DIEP surgeries. We’ll be watching with great interest to find out whether United concedes to the law or not. We figure a number of United’s current and potential future members will be watching, too.
