Clinical Care Teams Help Get Coverage After Denials

October 1, 2006

the impact the clinical care team can have on the outcome of a health plan's decision to cover a service or treatment

These two case studies illustrate the impact the clinical care team can have on the outcome of a health plan's decision to cover a service or treatment. Remember, you are the oncology expert, not the health plan or their reviewers, and that expertise can make a profound difference in your patients' lives outside of the clinical setting.

In both of these case studies, without the assistance of the clinical care team, these patients' survival would have been in serious jeopardy. Your influence expands beyond the hospital or office, and your input in these situations can be critical.

Jean is a 74-year-old retired accountant with a long history of abdominal pain. She is also hypertensive and has osteoarthritis. Recently her abdominal pain increased to the extent that she could barely walk and she needed to lie down most of the time. After a particularly bad episode, Jean called 911 and was taken by ambulance to her local hospital.

Jean was admitted to the ER with pain and diffuse abdominal tenderness. She received additional pain medicine and IV fluids. Her primary care physician admitted her to the hospital and scheduled her for a CT scan of the thorax and a CT-guided abdominal biopsy. The CT scan of the thorax was normal, but the abdominal biopsy was consistent with a diagnosis of ovarian cancer.

Jean began chemotherapy while in the hospital. Instead of being discharged to home with nursing care, she was released into the custody of her daughter, who lived locally. Jean remained with her daughter until she completed chemotherapy and demonstrated that she could perform daily activities. At that point, she felt well enough to return home.

While at her daughter's house, Jean received notification from her insurer that they would cover her ambulance ride and her ER stay, but not her 2-day in-patient hospital stay. The health plan claimed that all the procedures she received during her hospital stay could have been done on an outpatient basis. The plan said Jean should have remained in the ER under observation until her pain was under control, and once stabilized she should have been discharged.

Appeal Strategy

Jean's daughter looked for help in her mother's appeal of the denial and found the Medical Care Ombudsman Program (MCOP). Subsequently, MCOP put together a panel of experts that included specialists in medical oncology and pain medicine. The panel was in complete accord that the inpatient stay was medically necessary and should be covered by the health plan.

The panel agreed that Jean's pain, discomfort, and medical instability were evident on her chart review. The appropriate services for her condition included ambulance transport to the ER and the ER's evaluation to ascertain the level of her pain, the need for and type of analgesia she would require, and her overall clinical status. The panel further concluded that her admission after consultation with specialists and her primary care physician were necessary and appropriate. Jean required the biopsy so that her diagnosis could be confirmed and her curative chemotherapy and palliation of symptoms could be administered as expeditiously as possible.

Additional factors raised in the appeal letter in support of coverage of Jean's inpatient stay included her advanced age, her fragile physical condition, and her difficulty walking even when she was not in pain. According to her primary care physician, other factors that also required consideration included the distance she lived from the hospital and the fact that she was on her own and had no caregiver on her premises. It was clear to the panel that the health plan had not taken these factors into consideration when rendering the initial denial of coverage.

Resolution

The health plan scheduled an appeal hearing, and Jean's primary care physician and oncologist participated via a conference call. The health plan administrative officer remained steadfast about the denial of coverage. In contrast, the health plan medical director spoke forcefully about the factors that their in-house reviewer disregarded when rendering the denial and advocated that based on the information at hand, Jean's inpatient stay should be covered.

Jean's primary care physician indicated that their state had a state-mandated appeal program, and if coverage of the hospital stay was not approved at this level, he was sure that the nature of the case would compel coverage as medically necessary at the state level; then the company would have to bear the cost of the review, in addition to the coverage of the hospital stay.

The appeal hearing adjourned without a decision. A week later a letter from the health plan arrived approving the inpatient stay and indicating that Jean could choose case management for the rest of her cancer treatment.

Lessons Learned

• It is important to read denials closely for inconsistencies with the patient's history and presentation. Sometimes the health plan reviewer misses, or is not aware of, factors that can alter the decision-making process.

• It is important to document any factors affecting the patient, such as mental state, fragility, available help in the home or from family or their absence, rural location, and difficulty in getting to and from procedures—these can make a difference in terms of services allowed.

Case 2: Treatment for Recurrence

Larry is a 45-year-old man recently diagnosed with a right frontal glioblastoma. The tumor was resected, with follow-up care consisting of radiation therapy and temozolomide (Temodar). Larry's most recent MRI revealed some areas suspicious for recurrent disease, which was later determined to be nonresectable. Larry's oncologist recommended irinotecan (Camptosar) and bevacizumab (Avastin) to treat his recurrence. His insurer refused to cover the regimen on the basis that his records, as interpreted by a plan medical reviewer, showed clinical stability, and, as such, treatment was not necessary at this time.

Appeal Strategy

Larry's oncologist was also a reviewer for MCOP and suggested that Larry contact MCOP for assistance in crafting an appeal strategy. To expedite the plan's decision-making process, MCOP contacted the plan's medical director and discovered that Larry's records had been examined by an internist with no oncology experience. It was further discovered that no cancer specialist or neuro-oncologist was involved in the review.

MCOP suggested that the appeal be placed in abeyance so that MCOP could have one of its neuro-oncology experts review Larry's situation. The price was right, gratis, and the medical director agreed to this plan, particularly since their plan did not have access to neuro-oncology expertise. All parties agreed that after receipt of this review, the medical director would determine whether an appeal was necessary. MCOP assigned a neuro-oncologist to review the case on an expedited basis. After reviewing the MRI and other reports provided, MCOP's neuro-oncologist concluded that Larry did indeed have progressive disease. The reviewer further commented on the treatment recommended, indicating that there is no standard therapy at this stage of recurrence. There is also limited literature on the efficacy of this regimen. However, he stated that abstracts, presented at a recent national cancer meeting and provided as part of Larry's appeal, were promising, and said that his personal experience with the regimen supported its use. He also indicated that other standard protocols available have low success, and this promising regimen would be expected to be more beneficial.

Resolution

The plan's medical director appreciated the difficulty of the situation, but remained steadfast that his personnel could not be faulted for their initial interpretation of the records. He appreciated the neuro-oncology's expert review, and the fact that the neuro-oncologist had agreed to consult on similar difficult cases in the future.

Based on all of the factors presented in the reviewer's letter and telephone conference call, Larry's treatment was summarily approved. The entire process—from denial, to MCOP contact, to reviewer opinion and conference with the medical director—took less than a week.

Lessons Learned

• You never know what you can work out until you ask. A conversation with a health plan's medical director, physician to physician, can identify or resolve issues needing clarification, particularly when in-house expertise is unavailable. Without finger pointing, providing expert consultation can resolve the problem standing in the way of approval.

• In this case, the expert reviewer agreed to help in future neuro-oncology cases thereby ensuring that patient interests were adequately represented.