Kantor & Kantor Wins Appeal Forcing Blue Shield to Pay for ICU Treatment for Client with Brain Cancer

Glioblastoma, also known as glioblastoma multiforme, is an aggressive type of cancer that can occur in the brain or spinal cord. Glioblastoma can occur at any age but tends to occur more often in older adults. Many glioblastoma symptoms develop slowly and get worse over time. Common symptoms may include:

  • Headaches
  • Loss of appetite
  • Loss of balance or trouble walking
  • Mood swings
  • Nausea and vomiting
  • Personality and behavior changes
  • Problems speaking
  • Problems with memory
  • Seizures
  • Sensation changes
  • Trouble concentrating
  • Vision changes
  • Weakness

Glioblastoma can be very difficult to treat, and a cure is often not possible. Treatments may slow progression of the cancer and reduce signs and symptoms.

Our client was on MediCal in 2020. In May 2020 he was diagnosed with glioblastoma. His treatment regime included chemotherapy (pill) every two weeks and an injection of Keytruda (an immunotherapy often used with other drugs or chemotherapy to treat certain types of cancers) every three weeks. The client underwent MRIs and CT scans regularly to monitor the progression of the tumor.

Fast forward to January 1, 2021, at which time the client switched to a Blue Shield PPO plan. On February 3, 2021, the client was rushed to the hospital after suffering a blood clot and stroke. He was admitted to the Intensive Care Unit (“ICU”) where he stayed until February 7, 2021. Blue Shield denied the client’s ICU treatment stating it was not medically necessary.

The client and his partner were completely shocked that Blue Shield would not pay for the ICU treatment and immediately contacted Kantor & Kantor. Recognizing that the insurance company’s denial was improper and completely absurd, Kantor & Kantor acted quickly and filed an appeal. As a result of Kantor & Kantor’s efforts Blue Shield overturned their denial and authorized the client’s ICU treatment.

If your insurance plan refuses to approve or pay for a medical claim, including tests, procedures or specific care ordered by your doctor, you have guaranteed rights to appeal. Review your denial letter carefully as it outlines your next steps for appealing their decision.

Your insurer must provide to you in writing:

  • Information on your right to file an appeal
  • The specific reason your claim or coverage request was denied
  • Detailed instructions on submission requirements
  • Key deadlines to submit your appeal
  • The availability of a Consumer Assistance program, if available in your state

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.

 

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