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Linda Farina – Metromedia Restaurant Group |
October 29, 1999 |
Dear Healthcare Gatekeepers:
I must apologize for being so long in writing this letter. I’ve had several bad months of "brain fog", followed by a "white page", can’t get started blockage.
First of all, let me say, there is no doubt in my mind; when a benefit has a legitimate basis for being disallowed, that should be the end of it.
The MRG "Plan" presents a fairly clear picture of what is generally disallowed, and what is generally allowed. When determining "Medical Necessity," it is also quite specific:
"OO. Medically Necessary means a medical procedure or supply that satisfies all of the following:
(1) It must be legal;
(2) It must be ordered by a Physician;
(3) It must be safe and effective in treating the condition for which it is ordered;
(4) It must be part of a course of treatment which is generally accepted by the American medical Community, including all branches of professional societies and governmental agencies;
(5) It must be of the proper quantity, frequency and duration for treatment of the condition for which it is ordered.
(6) It must not be redundant when it is combined with other services and supplies that are used to treat the condition for which it is ordered;
(7) It must not be Experimental/Investigative;
(8) It must not be maintenance therapy or treatment; and
(9) Its purpose must be to restore health and extend life."
No qualms or quibbles there; the definition seems to be boilerplate for many "Plans."
Where my most consistent (although not the only) point of contention is what is supposed to happen when a claim receives an adverse action. The following is not from the "Plan," but from the law itself:
"shall provide to every claimant who is denied a claim for benefits written notice setting forth in a manner calculated to be understood by the claimant:
(1) The specific reason or reasons for the denial;
(2) Specific reference to pertinent plan provisions on which the denial is based;
(3) A description of any additional material or information necessary for the claimant to perfect the claim and an explanation of why such material or information is necessary and;
(4) Appropriate information as to the steps to be taken if the participant or beneficiary wishes to submit his or her claim for review."
29 C.F.R. @ 2560.503-1(f).
Notwithstanding Mr. Esler’s opinion that Metromedia Restaurant Group, in form, complied with the "Plan" (after all, his firm is the author) and the "Law," all the actions, statements, EOBs and positions taken by all addressees failed in substance. Every one of your denials failed to provide, "…in a manner calculated to be understood by the claimant" (that’s dumb ol’ me) the criteria of actions (1), (2), and (3) when a denial takes place. Action item (4) had some semblance of compliance, since the fine print at the bottom of the EOBs said consult the Plan document for procedure(s).
Simply, if a denial took the form of "Medical Necessity Not Established," for me to understand what the heck you are hanging your hat on, you will have to spell out which of the nine definition items of "Medical Necessity," if any, the claim failed. Remember the word "specific"? Coupled with that, you should have provided the item (3) information required of me or my provider in order to perfect the claim. What does it really take; a statement of medical necessity by the doctor, peer-reviewed information showing the acceptance of the treatment or supply (which we have done to the best of our ability, but we were only guessing on what was required. You never spelled it out)? In each of the questioned adverse decisions, you have failed to address denial action (3) in any form or fashion.
The "Plan," and the law, allows me, when appealing an adverse action on your part, to "(b) submit written issues and comments to the Administrator." This I have done: about three inches worth. However, this information was either ignored, or not forwarded in entirety to contracted reviewers.
Ms. Jones, the law, and others, have pointed out to me that the plan states "the plan administrator determines, in the exercise of its discretion" what is really covered. In other words, you make the rules. What is bothersome though, is when you continuously violate those rules, to my disadvantage.
So, it boils down to two different points of view when exercising that discretion:
The objective – "There is no evidence that…."
The subjective – "It cannot be ruled out that…"
I will take just one point of the "full, fair, and final" review as an example. This concerns the denial for use of Rocephin. The first denial stated "Intramuscular injections not effective for eradication of Lyme disease*," with the amplifying footnote of "*Medical literature indicates that it is not possible to deliver an effective treatment dose for eradication of Lyme disease with this antibiotic using the intramuscular route, as 2 mg. Daily intravenously are required to accomplish this. Documentation includes "Lyme Borreliosis and Related Disorders," by Kenneth Liegner, MD and Conn’s Current Therapies."
As I first pointed out in my November 21, 1998 letter to Linda Farina; "Perhaps the 2mg listed in the footnote is a typo; 2mg is totally inadequate. " However, the same footnote was included in the 4/30/99 spreadsheet from First Health. As everybody should know by now, the recommended start value is 2g. Then, depending on clinical observation, patient reaction, etc. the dosage and frequency is adjusted.
Since the (unnamed) First Health Medical Director and/or the (unnamed) Physician Consultant cited Conn’s Current Therapies (which my healthcare provider also uses), I also provided the following extracts from the cited literature:
"The Conn's Current Therapies section on Lyme Disease, written by Joseph J. Burrascano, Jr. MD is THE BIBLE on Lyme Disease (LD) since at least 1989. Conn's is a standard reference text for treating physicians.
"There is no universally effective antibiotic for treating Lyme Disease. The choice of medication used and the dosage prescribed will vary for different people based on multiple factors."
"Drug levels are done until the most acceptable dose is achieved and then at any time major changes in the treatment regimen occur."
"All patients respond differently and therapy must be individualized. It is not uncommon for a patient who has been ill for many years to require open ended treatment regimens; indeed, some patients will require ongoing maintenance therapy to remain well." "
In my February 3, 1999 letter to Ms. Thompson, I reiterated the above quotes, and added:
" "As a final retort to the nameless physician consultant's ludicrous statement that 1 G IM is not appropriate, allow me to quote from Dr. Burrascano's October 1998 edition:
"Oral preparations are acceptable for maintenance, but most need parenteral dosing: 1 gram IV or IM (emphasis mine) at least weekly until neuromuscular irritability has cleared."
Parenteral includes IV and IM administration routes. "
Additionally, only 25% of chronic Lyme patients are lucky enough to receive certification for IV antibiotic therapy; IM is the more prevalent route of administration due to cost and TPA denials. We did attempt, in a letter to Lucy Finger, to obtain authorization for the IV Rocephin therapy. Because of your retrospective stance on reviewing claims, and in light of your denial for the less expensive, recognized and appropriate treatment, we could go no further. Although the named fiduciary had the discretionary authority to grant and authorize the request, it was not exercised to my benefit.
In light of my probationary status at the time (due to the neuropsychiatric deterioration brought about by your treatment denials), with an Americans with Disabilities Act accommodation request on the table, with the pass-the-buck and rely on policy stance, you effectively denied the only treatment and rehabilitation possible to improve performance and allow me to be returned to a productive status with MRG.
Before going further, I would like to provide the following definitions of what, to me, are the keywords in your
fallacious denials for Rocephin. The definitions are taken from The American Heritage
Dictionary of the English Language, New College Edition, 1978, Houghton
Mifflin Company, Boston, Massachusetts:
Eradicate - …1. To remove all traces of; annihilate; erase.
Required - …1. Needed, essential.
Please keep these definitions in mind. They will be very important later.
Not bothering to refute or take into account my "(b) submit written issues and comments to the Administrator.," an independent reviewer (Dr. Gary Greenhood) was contracted through INTRACORP.
In Ms. Farina’s letter of March 3, 1999, she states:
"Regarding the second matter, MRG is in the process of arranging an independent medical review of your case. The physician under consideration to conduct the review is completely independent of First Health and has had no prior working relationship with MRG. The physician handles case reviews for INTRACORP, is a specialist in infectious diseases and has reviewed over 70 Lyme Disease cases in the last four years."
Then, in Ms. Farina’s letter of April 23, 1999, she states:
"As I told you in my letter of March 3, 1999, MRG arranged for a review of your medical records by a physician who is independent of First Health. The physician is Dr. Gary Greenhood, who has been working as a physician reviewer for Intracorp for several years and has reviewed over 70 Lyme Disease cases during the past 4 years. Dr. Greenhood has been in private practice for thirteen years specializing in infectious disease and internal medicine. He attended the University of California, receiving bachelor's degrees in chemistry and biochemistry and earned his medical degree from Stanford University School of Medicine. Dr. Greenhood also earned his MBS from Emory University in Atlanta, Georgia. He holds board certifications in internal medicine and infectious disease. Dr. Greenhood is a member of the American College of Microbiology, American College of Physicians and the Infectious Disease Society of Georgia.
Dr. Greenhood was provided with a copy of your medical records from Dr. Moayad. In addition, I sent Dr. Greenhood some of the correspondence you have directed to me over the last several months outlining your concerns with lack of reimbursement for certain claims submitted by Dr. Moayad, as well as some of the research articles you provided."
The emphasis on "some" is mine.
I’m curious about how someone can review 70 cases over four years, when The Georgia Division of Health states the number of reported cases in Georgia for 1996 were 9, and for 1997 (last year listed) is 1. I guess the keyword is "review," not "treat." I would also be interested in what the outcome was for each of those paid reviews.
Anyhow, Ms. Farina goes on to state that Dr. Greenhood utilized "(I) the 15th edition (1998) of Harrison's Principles of Internal Medicine and (ii) the 1998 Sanford Guide to Antimicrobial Therapy" for reference material. As I later pointed out, the 15th edition of Harrison’s has not been printed yet, so I obtained the 14th edition. Horror of horrors, I found the chapter on Lyme disease was written by Dr. Allen Steere. Attached you will find some information about why chronic Lyme patients call him Bum Steere. By the way, when this case reaches Federal Court, the two references introduced by Dr. Greenhood will be disallowed, as they were not part of the Administrative Record at time of appeal.
Using Dr. Greenhood’s references, you will in fact find they are recommendations and guidelines, not required. From my correspondence and research articles, it is quite apparent that the TREATING physician is quite within medical necessity bounds administering 1g or 2g IM.
The real clincher though comes from Dr. Greenhood’s Sanford guide. An Editorial Note states "…Some of the recommendations in the Sanford Guide suggest use of agents for purposes or dosages other than recommended in product labelling. Such recommendations are based on reports in peer-reviewed publications; they are not based on direct input from any pharmaceutical manufacturer. They are made only with due consideration of the concerns of the Food and Drug Administration for "off-label" uses. We have attempted to identify such as "not FDA-approved" for this indication."
The Sanford Guide also contains many footnotes and abbreviations. The one that really caught my eye is "The recommended dosages and durations is a minimum or average, and should not be construed as absolute."
This kind of contest can go on and on. For every peer-reviewed article or text you find that says X, I can find multiple peer-reviewed articles or texts that say Y. In light of the Bakken et al findings (Performance of 45 laboratories participating in a proficiency testing program for Lyme disease serology JAMA 1992 Aug 19;268(7):891-5), when an ordered test returns equivocal results that fly in the face of clinical observations, tests are reordered as a matter of course.
Perhaps the TPA industry case managers should take a more active hand in overseeing accreditation standards of the laboratories, rather than take it out on the treating physician and patient. Lab Corp seems to be a PPO for First Health, yet they only have one reference laboratory. In the public record concerning this PPO are too many instances of mishandling, mislabelling, contamination, unreliable results, and contradictory results with split samples.
So it comes down to (taking an objective viewpoint) – you have evidence that supports your opinion, I have evidence that supports my physicians opinion (shared by most treating physicians.) The opinion of the treating physician is entitled to great weight, in insurance and in Medicare cases. (See Schisler v. Heckler, 787 F 2d 76, 81 (2d Cir. 1986); Klementowski v. Secretary, 801 Fed Sup 1022. These cases say that the treating physicians certificate of medical necessity is binding unless contradicted by substantial evidence.
Also, looking at things subjectively, neither position can rule out the opposite position. There is too much published, contradictory material for either the objective or subjective school of thought to reign. This is why clinicians, unlike academicians, utilize a non-universal, individualised treatment course with each of their patients. They are seeing the wax-and-wane of a living breathing human, not an isolated, cultured organism.
For those who have Internet access, going to The Bacterial Revolution just might allow you to see why I trust my treating physician and confirmatory second-opinion physician, rather than any remote reviewer.
Now to the eradication claim. There is no known test that can definitively show a "cure" for Lyme disease. Rather, the Bb spirochete has been isolated from the skin [1,2], spinal fluid [2,3], synovial fluid [4], blood [5], ligamentious tissue [6], muscle tissue [7] and iris tissue [8] of patients after antibiotic therapy, including intravenous (IV) and/or long courses of supposedly curative antibiotics.
[1] Hassler D et al: The Lancet 338, 193 (1991)
[2] Preac-Mursic V et al: Infection 17, 355 (1989)
[3] Pfister H et al: The J of Infectious Disease 163, 311 (1991)
[4] Schmidli J., et al; Cultivation of B. burgdorferi from Joint Fluid Three Months After Treatment
of Facial Palsey Due to Lyme Borreliosis; J. of Infectious Disease 158: 4, pg 905-906 (1988)
[5] Masters E et al: "Spirochetemia Two Weeks post cessation of six months of continuous p.o. Amoxicillin
Therapy" (Abstr. 65, Fifth Int'l Conf on Lyme Borreliosis, Arlington, VA; 1992)
[6] Haupl T et al: Arthritis & Rheumatism 36, 1621 (1993)
[7] Hoffmann JC et al: Lyme disease in a 74 year old forest owner with symptoms of dermatomyositis.
Arthritis Rheum 38, 8: 1157-1160 (1995)
[8] Preac-Mursic V et al: J of Neuroloophthalmology 13, 155 (1993)
Once the active infection caused by Bb is controlled with antibiotic treatment, many patients continue in this improved state for the rest of their lives. However, there are estimates that one-third of late stage Lyme patients are at risk for developing chronic Lyme, where any immunodeficiency crisis (stress, infection, cancer, etc.) allows the "hidden" spirochetes to emerge and reinfect the patient, requiring another course of treatment. Relapse can also occur if treatment was not of sufficient duration. This insufficient duration usually comes about through denials by insurance or TPA review, and exhaustion of personal assets by both the patient and physician.
When a relapse occurs, the prudent physician may perform tests that had previously been done, even if unremarkable at that time. This has a two-fold purpose: to try and find out what went wrong (caused the relapse), and also asking themselves "why is my patient not getting better, is it possible that I'm missing something, is it possible that I was wrong in the first place or maybe I was right in the first place but there's something else going on now."
After all, "…Into whatever houses I enter, I will go into them for the benefit of the sick, and will abstain from every voluntary act of mischief and corruption…". This would include admitting that you may be wrong.
I know you folks are just trying to save MRG money. You continue to take the objective position, even if it brings me harm. If, however, you took the subjective position that every clinician uses, you would see the lubricious nature of your denials.
For instance, in Ms. Farina’s April 23, 1999 letter [for Dr. Greenhood] she states:
1) Dr. Greenhood agrees with the First Health Medical Director (FHMD) that the TORCH screen from January, 1996 was not medically necessary. According to Dr. Greenhood, the TORCH screen measures antibody responses to toxoplasmosis, rubella, cytomegalovirus and herpes simplex viruses type 1 and 2. Dr. Moayad's records indicate that he ordered these tests to evaluate a possible immunodeficiency state, arthralgias and arthritis, questionable varicella-zoster recurrence, and possible herpes simplex type 2 disease; no mention of an actual viral culture from any lesion is noted in the submitted material. According to Dr. Greenhood, the microorganisms assayed via TORCH serology would not be expected to fit into a differential diagnostic list of entities causing these signs and symptoms. Therefore, this charge is denied as not being medically necessary, as defined in the Plan (section 7.2, pages 51-52).
I have attached a very simple fact sheet about TORCH screens. It can be found in almost any pediactric health encyclopaedia. Given the known cross-reactivity of many viruses, my 28 month tour in the Republic of Viet Nam (many times eating off the local economy), and raising show cats (max of 36) would quite appropriately allow a doctor to order tests to start a ruling-out process. As you will notice on the TORCH screen fact sheet, there are many similar symptoms, WHICH I EXHIBITED AT THE TIME. Each must be performed to pin-point, or eliminate. Using the TORCH screen is more effective than individual tests (check out laboratory charges), even if ONE of those tests may be redundant.
Both the 10/23/98 and 04/30/99 spreadsheets carry the denial reason explanation "Not Med. Nec, Torch Screen is For Poss Exposure to 4 Diff Organisms, Only 1 of Which Could Even Remotely Be Considered As The Cause For Patients Illness". Hmmm, "remotely", sounds a lot like "It cannot be ruled out that…"
I can hear the retort, "...there was insufficient documentation by Dr. Moayad for us to decide." Go back and read the "Plan" definition of "Medical Necessity." Nowhere do you find anything about "AND document to our [unpublished] standards." If you cannot make a determination on a claim is where denial action "(3) A description of any additional material or information necessary for the claimant to perfect the claim …" There is no evidence that you have done so.
As I pointed out to Ms. Thompson in my February 3, 1999 letter:
"From Dr. Burrascano's 12th edition (October 1998):
"Lyme is diagnosed clinically, as no currently available tests, no matter the source or type, are definitive in ruling in or ruling out infection with these pathogens, or whether these infections are responsible for the patient's symptoms. The entire clinical picture must be taken into account, including a search for concurrent conditions and alternate diagnoses, and other reasons for some of the presenting complaints. Often, much of the diagnostic process in late, disseminated Lyme involves ruling out other illnesses and defining the extent of damage that might require separate evaluation and treatment ."
"Regular blood counts and liver panels are recommended during any prolonged course of therapy"
" Since blood levels are extremely variable they should be measured."
"The treating physician may decide on chronic therapy in order to avoid clinical deterioration. Recommend
you confirm blood levels, and study immune competence. This includes T- and B- cell function and counts, Natural
Killer cell functional assays, complement levels, neutrophil function, and vaccine responsiveness."
"Drug levels are measured until the most acceptable dose is found, and then at any time major changes in the
treatment regimen occur. With parenteral therapy, CBC and chem/liver panels are done at least twice each month
during symptom flares, with urinalysis and prothrombin time monitored monthly.""
I would have no quibbles with the (unnamed) First Health Medical Director, (unnamed) first reviewer, or Dr. Greenhood if they were honest enough to say "I wouldn’t do it this way in my practice," but to not certify something as medically necessary based upon spurious reasoning borders on the criminal, and sure as hell violates "…will abstain from every voluntary act of mischief and corruption…" I do know a number of CIGNA (parent company of INTRACORP) patients share my view about Dr. Greenhood’s denial reasoning.
I apologize to any and all if you might feel I’ve cast unjust aspersions. Perhaps some of you are seeing this information for the very first time. Somebody seems to have been a gatekeeper; selective in distributing information they feel pertinent to their cause. This is all well and good in the normal commerce of business, it helps you address everything point-by-point. However, when it comes to a full and fair review of human suffering, the entire Administrative Record should be examined. If you examine the discrepancies listed in the attached spreadsheet, you will find that the review process was not full, and decidedly not fair.
This will be my last address to this 1996-1997 appeal circus. From this day forward my flagging energies will be devoted to legislative and media functions.
In closing; I remember back when I was capable of gainful employment. I took great pride when Michael Kaufman rededicated MRG’s commitment to integrity and ethics. I remember his statement "Any manager or executive who causes, or has knowledge of and does nothing, harm to any employee will be instantly dismissed."
Too bad he didn’t mean it.
May your careers be as foreshortened as my life-span.
R. James Martin
Attachments
url of this page https://www.angelfire.com/biz/romarkaraoke/vent001.html
