Are Insurance Third-Party Reviewers Denying Patients Access to Necessary Treatments?

Four years ago, a 22-year-old man underwent multiple exploratory surgeries and biopsies to treat his painful symptoms and was diagnosed with SVP Vasculitis, which is an auto-immune disease that causes inflammation of the blood vessels. This disease can be fatal. Luckily, the young man was told by his rheumatologist that Cytoxan, a chemotherapy drug proven to treat vasculitis since 1970.

A few days later, the patient’s health insurance company forwarded his claim to the Medical Review Institute of America, which is one of many paid third-party reviewers, to help assess the cost and determine whether the insurance company would cover this treatment. The third-party reviewer advised the insurance company to deny the patient’s request for life-saving, medically necessary treatment. This denial is an alarming trend in the health care industry.

After persistently asking for the specific denial letters regarding the patient’s case, he became confused at what he read. The reasons for his denial were actually taken from medical literature that proved the opposite—Cytoxan works to treat SVP Vasculitis. He also found the “experts” claiming this treatment would not save his life were urologists, who were extremely unqualified to recognize a viable treatment plan for cancer or auto-immune diseases.

After a fourth appeal and a final “no” from his health insurance company, the patient enlisted in an attorney who helped him receive a proper review from a board-certified rheumatologist and finally got the approval from his insurance company. However, his story brings to light the frightening fact that this happens all too often to patients who do not necessarily know they should or could refute insurance third-party reviewers.

Health Insurance Company Third-Party Reviewers Can Withhold Life-Saving Treatments

If your insurance company is denying a treatment that could either cure a condition, save your life or vastly improve your quality of life based on a recommendation from a third-party reviewer, you should contact an attorney to look over your denial letters and see if the reviewer is actually qualified to contradict your doctor’s treatment recommendation. Your insurance company may be covering a bulk of the costs, but you as a patient have rights to medically necessary treatments.

“Now faith is confidence in what we hope for and assurance about what we do not see” Hebrews 11:1