Oct 31, 2014

Insurers Have to Use the Correct Criteria in Evaluating Medical Necessity


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12/31/2010
Brian S. King
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Last week I received an excellent decision from Judge Dale Kimball in federal district court for the District of Utah, James F. v. CIGNA Behavioral Health.  I've placed it in the website library

James's daughter, C.F., had serious mental, emotional and behavioral problems that required acute inpatient mental healthcare.  When she had stabilized her treating doctors recommended that she be treated inpatient on a sub-acute basis at a residential treatment center.  Her parents admitted her to Island View Residential Treatment Center.  CIGNA Behavioral Health (CBH) refused to authorize coverage for Island View asserting that C.F.'s condition did not satisfy CBH's internal medical necessity criteria.  Thus, CBH said C.F.'s residential treatment was not covered. 

James retained me to represent him and we brought suit against CBH to recover the unpaid medical expenses.  Judge Kimball reversed CBH's denial.  He ruled that CBH had utilized improper criteria in evaluating C.F.'s condition.  He also faulted CBH for cherry picking C.F.'s medical records and ignoring the opinions of her treating physicians.  Finally, CBH attempted to present for the first time in litigation reasons it denied the claim.  Because these reasons had never been communicated to the family when the claim was initially denied, the court refused to consider them.  The court ordered CBH to pay C.F.'s residential treatment at Island View. 

I wish I could say that how CBH treated C.F.'s residential treatment claim was uncommon.  But the fact is that insurers regularly use improper criteria to evaluate coverage of residential treatment. 

Category: General


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