JC
First Health Appeals Department
World Houston Plaza
15710 JFK Boulevard, Suite 500
Houston, Texas 77032

September 13, 1998

Dear "JC",

Thank you for your letter that finally determined that no pre-existing condition existed. However, your findings appear to grossly tardy, in light of "The Plan", Section 7.11, final paragraph.

Reviewing the entire letter, I must first say that some of the statements need correction:

1. It is Dr. Xxxxxx, not Dr. "XXXXX" as you repeatedly stated in your letter. It is correctly spelled in the enclosed spreadsheet"

2. In your third paragraph, ... ""provides coverage for "Service or supplies which the plan administrator determines, in the exercise of its discretion, are generally acceptable by the national medical professional community as being safe and effective in treating a covered illness or injury, consistent with the symptoms or diagnosis, furnished at the most appropriate medical level and not primarily for the convenience of the patient, a health care provider or anyone else".""

My representatives and I have reviewed the plan document ("The Plan") multiple times. Nowhere can we find the quoted sentence. Rather, it seems to be a misquoted conglomeration of various plan definitions. While it does appear to be a quote from the Summary of Plan Benefits; in cases of conflict, "The Plan" language obtains. We have also reviewed Dr. Xxxxxx's submitted information, and cannot find how it could be construed as violating any provision of Section 7.12.R, or Section 7.12.00.

3. In your fourth paragraph, ... "you have also requested information regarding covered CPA and ID-9 codes and descriptions".

The e-mail requested:

1. Covered CPT Procedure Codes
2. Related CPT Procedure Codes
3. Local Codes for adjunct treatments
4. Covered ICD-9 Diagnosis Codes
5. Description Of The Diagnosis
6. Plan Policy --

a. Medical Necessity/Appropriateness
b. Medical Policy Background
c. Documentation Requirements
d. Utilization Review Parameters
e. Preauthorization Requirements
f. Coding Guidelines
g. Diagnostic Testing
h. Professional Review Parameters
i. Medical Policy Background Disease Characteristics:

(1) Disease Characteristics
(2) Diagnosis --

(a) Musculoskeletal System
(b) Nervous System
(c) Cardiovascular
(d) Serologic Testing

(3) Treatment

7. Appeal Process --

a. time limits
b. documentation requirements

Although we have provided the enclosed documentation previously to Metromedia Restaurant Group, perhaps it was not forwarded to you, or your "a clinical physician and nursing staff" are not conversant with the "The Plan" or current on medical literature. We do know for a fact that Dr. Xxxxxx has forwarded the relevant pages from Conn's Current Therapy directly to you that should sufficiently establish "medical necessity".

To clarify the need for CPT and ICD-9 codes, we have attached similar discovery findings; these are standardized literature that your medical, nursing, and coding staffs should be relying on when making initial evaluations, subject to "The Plan" provisions and existing law. Perhaps an internal review of your procedures is in order.

I would also call your attention to "The Plan" Section 7.14.G. Since other eligible members of "The Plan" have received an "eligible expense" determination for the identical procedures and services, I believe that ... "all persons similarly situated will receive substantially the same treatment." should apply. To deny this treads dangerously close to the "arbitrary and capricious" area of the governing 29USC and the Texas Administrative Code.

Despite repeated calls to your "customer service" line, and repeated direct appeals to the MRG HR Department, the provisions of "The Plan" Section 7.18.D have not been complied with. You have not satisfactorily (in language we can understand) provided:

Reason for denial;
The Plan provisions on which it is based;
Any additional material or information needed to make the claim acceptable and the reason it is necessary;
The procedure for requesting a review

Please do so.

Finally, the spreadsheet you enclosed with the factually challenged letter contained "Reason For Denial" statements that appear nowhere the "The Plan" document. Since the spreadsheet did not contain the procedure, diagnosis, or service-provided information, we cannot at this time address each one with specificity. If you would provide this amplifying information, along with supportive documentation (in the form required by "The Plan" and other governing authorities) to substantiate, it would help greatly.

Progressively worsening,

R. James Martin


cc: Linda Farina
Dr. Xxxxx Xxxxxx
Administrative Record

enclosure(s):

1. Copy of your August 31, 1998 letter
2. pre-trial discovery findings (sample of CPT and ICD-9 request)
3. American College of Physicians - "Guidelines for Laboratory Evaluation in the Diagnosis of Lyme Disease", Part(s) 1 and 2.
4. Dr. Joseph J. Burrascano's "Managing Lyme Disease" found in current edition of "Conn's Current Therapy"

First Health Reply: Director & Associate Counsel
First Health Reply: Manager, Support Services