Health insurance plans provide coverage only for health-related serves that they define or determine to be “medically necessary.” Medical necessity refers to a decision by your health plan that your treatment, test, or procedure is necessary for your health or to treat a diagnosed medical problem.
Most health plans will not pay for healthcare services that they deem to be not medically necessary. The most common example is a cosmetic procedure, such as the injection of medications to decrease facial wrinkles or tummy-tuck surgery. Many health insurance companies also will not cover procedures that they determine to be experimental or not proven to work.
Hereditary Leiomyomatosis and Renal Cell Cancer (“HLRCC”) is a very rare genetic condition that was named in 2002. It is also known as Reed’s Syndrome. HLRCC is a disorder in which affected individuals tend to develop benign tumors containing smooth muscle tissue (leiomyomas) in the skin and, in females, the uterus. This condition also increases the risk of kidney cancer. Surveillance and monitoring for HLRCC is recommended starting at around age 5-8 years.
A client, whose name is being kept anonymous to protect her privacy, contacted Kantor & Kantor recently for help with insurance denials for both of her children. The woman was diagnosed with HLRCC and had been undergoing annual screening with an MRI. More recently, both of her children (ages 10 and 12) underwent genetic testing and were diagnosed with HLRCC. The children’s treating doctor, a pediatric hematologist and oncologist, requested pre-authorizations for abdominal MRIs for both children. The MRI exams were initially approved and authorized in December 2019, however the client was unable to schedule MRI exams for both children before the end of the calendar year. In January 2020, the client’s husband’s employer switched insurers and when the children’s pediatric hematologist oncologist submitted the pre-authorization requests to the new insurance company for both children to undergo abdominal MRIs, both requests were denied stating, “this test is not medically necessary for you.” The treating doctor submitted an appeal for both children and insurance company upheld their denials.
Recognizing that the insurance company’s denials were improper, Kantor & Kantor acted quickly and filed requests for independent external reviews of Anthem’s denials. As a result of Kantor & Kantor’s efforts the insurer overturned their denials and authorized the abdominal MRIs for both children as medically necessary.
Our client’s case is not uncommon. Health insurance plans routinely deny health insurance claims relying on blanket exclusions that ignore medical facts and current medically-based standards of care. Health insurance plans have appeals processes that allow patients and their doctors to appeal when a pre-authorization request is rejected, or a claim is denied.
If you or someone you know has been denied coverage for medically necessary treatment, please contact Kantor & Kantor at 888-569-6013 or use our online contact form for a free consultation. We understand, and we can help.