Peeking Behind the Curtain at Medical Insurance Decisions
Several years ago, I tried to get my insurance company to approve a functional electronic stimulator (FES). It’s a durable medical device that significantly improved my left foot drop. My request was well-supported by documentation from my neurologist and the physical therapist who was evaluating me for the FES. With the device, a Bioness L300, I was more stable, walked faster, and my risk of falling was decreased. But my insurance company denied the $6,000 device and my two appeals were also turned down.
I wasn’t particularly surprised when I later learned that the doctor who denied my final appeal had no background in neurology, physiology, or treating MS, but I was a bit angry.
CNN report draws back the curtains
Fast-forward a number of years to 2018. The insurance commissioner in California recently launched an investigation into Aetna‘s insurance practices after learning that a former medical director for the insurer admitted under oath that he never looked at patients’ records when deciding whether to preapprove care.
CNN obtained a transcript of videotaped testimony by Dr. Jay Ken Iinuma in a lawsuit brought by a 23-year-old college student in California who has a rare immune disorder. The patient sued Aetna for alleged breach of contract and bad faith because Iinuma denied pre-authorization for an infusion the student needed a few years ago. His suit alleges that Aetna’s “reckless withholding of benefits almost killed him.”
Iinuma served as medical director for Aetna in Southern California from 2012 to 2015, and he’s the person who denied the treatment. According to the CNN report, “Iinuma — who signed the pre-authorization denial — said he never read [the patient’s] medical records and knew next to nothing about his disorder.”