FIRST HEALTH Strategies (TPA), Inc.
February 3, 1999
15710 JFK Blvd., Suite 500
Houston, TX 77032
Attn.: Mary Jo Thompson
Dear Ms. Thompson:
Attached is a letter from Linda Farina, Senior Director Employee Benefits for Metromedia Restaurant Group (MRG). In that letter, she has made the determination that my September 13, 1998 letter is a FIRST appeal, not a final appeal as you and Margaret B. Jones had previously elected .
I am not including my November 21, 1998 letter to Linda Farina that was a response to your November 5, 1998 letter , and Margaret B. Jones' November 5, 1998 letter. Ms. Farina has informed me by e-mail that she has forwarded that document to you.
I will attempt to keep my appeal simple. That way nobody should get lost (deliberately or not) chasing improper references and ignoring the substantive issue(s).
The only issue is, and still remains (despite repeated and specific requests), the continuous failure by FIRST HEALTH to comply with the specifics of the MRG Plan.
As Ms. Farina has outlined in her letter:"1) Generally, you will receive written notification of the denial within 90 days after the filing. The notice explains:
the reason for denial;
This mirrors my own repeated requests. In referring to the nine page spreadsheet attached to your November 5, 1998 letter to me, there are many, many references to MEDICAL NECESSITY NOT ESTABLISHED , or a form thereof.
Quoting from your letter, you state:"Some claims were denied as not being medically necessary as that definition is found in the MRG Plan document (see, plan document at pp. 51-52) ."
That Plan document states:
"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."Based upon the Plan definition of Medically Necessary , the Plan documentation requirements for explaining a denial, and coupled with the legal requirement that the explanation be in language I (a prudent layman) can understand, your previous reviews and ongoing administration fail on the following points:
In other words, for those items that you label with the various forms of a Medical Necessity denial, I would expect to be informed which, if any, of the nine points defining Medical Necessity the claim failed. Along with that information, I would also expect to receive the " any additional material or information needed to make the claim acceptable and the reason it is necessary" information needed to perfect the claim.
Without that information, your unamplified denial essentially states " Doctor, you provided a procedure or service that, in our medically informed opinion, the patient did not need, and there is no possible explanation we will accept to perfect the claim ". For a physician to make this determination without having directly examined the patient is manifestly unethical . However, if the Not Medically Necessary determination was made by a non-physician, the practicing of medicine without a license carries heavy penalties .
I do not want to be redundant, some of the following has been covered in previous communications. However, to preclude you having to retrieve the documents from wherever they seem to disappear to, I will cite them one more time:"...the spreadsheet provided more information than we've been able to obtain in the past, but is incomplete in form and substance, and is considered unresponsive. Until the required information is received, and understood by us, we do not possess the information we are entitled to on which to base an appeal.
However, there is an amplifying footnote on the attached spreadsheet that is extremely troublesome; it brings the qualifications and ethics of the unnamed reviewing physician consultant in doubt. The footnote states "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."
Surely the nameless physician consultant has heard of Jarisch-Herxheimer (Herx) reactions. The first IM Rocephin injection (paid for by First Health) was 2G IM. However, the Herx reaction was so severe, and the pain so excruciating that I couldn't get out of bed, much less drive to work. Using this "patient tolerance" indicator, it was decided that 1G twice a week was more tolerable. These are the charges First Health declared "not medically necessary," and did not pay for. If First Health isn't going to pay for the cheaper IM treatment, it is logical to assume that First Health is going to find a way to deny the more expensive treatment cited in their footnote. Dr. Moayad has been cost conscious throughout, and "enjoys" "enjoyed" a PPO status with First Health, at quite substantial discounts.
It is also quite apparent that the nameless physician consultant did not take into account complicating factors contained in my medical record, and cited as warnings in the literature. The IM route was chosen because IV treatment could not be undertaken while the patient is on high-dosage Coumadine. The depressed state of the auto immune system has a high probability of infection at the central line or PICC catheter insertion point. The surgery required to install a central line catheter has the danger of blood clot resulting in pulmonary embolism, especially in light of the protein-C clotting disorder.
By the way, in the texts cited by the spreadsheet footnote, there are no specific regimens for treatment -- they are only guidelines, modified by the treating physician using many factors. Perhaps the 2mg listed in the footnote is a typo; 2mg is totally inadequate.
We found two articles by Liegner with similar titles:
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.
Based upon the foregoing, it is quite clear the "standard" texts are only a preliminary starting point for developing treatment regimens; reliance on guidelines in these texts as the only authorized or effective treatment is erroneous in the real world. That there are patients requiring modifications and departures from "standard" treatment is not anecdotal.
From a scientific standpoint, there is no basis for a remote reviewer to arbitrarily impose a standard of care in which only the guidelines determine "medical necessity". The assertion that there is only one way to treat Lyme Disease is simply not supported by the data in peer reviewed scientific literature or other reference material. To disregard this data and impose an arbitrary standard of care is not good medicine and does a great injustice to patients who need treatment for chronic Lyme Disease.
Only a qualified treating physician, evaluating all presenting symptoms, patient tolerance to current regimens, complicating factors such as multi-systemic disorders, and the active state of the infection can ultimately determine "medical necessity" at any particular point in time."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.
Of course, I'm only conjecturing that the "neuromuscular irritability" is akin to a Herx reaction, which was the reason the treatment went from a single 2 gram IM injection weekly, to a 1 gram IM injection twice weekly.
On your spreadsheet, there also some REASON FOR DENIAL notations of:"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."
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 ."
The labeling of Sedimentation Rates , Prothrombin time , Thromboplastin Time , 19 Clinical Chemistry Tests (and other blood chemistry testing), Office Visit as Medical Necessity Not Established must be classified as stupid, mean, arbitrary, capricious, and downright malfeasance of office.
In light of Dr. Burrascano's recommendations (below), my medical history of chronic DVT, high Coumadin dosage, Protein C clotting disorder, and hypertension, Dr. Moayad's broad range of blood chemistry testing is not only prudent, it is imperative that concurrent conditions be monitored. The denials are way off base; they smack of misplaced cost containment attempts, not sound medical practice.
"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."
Perhaps the most egregious denial reason postulated is your usage of a "global charge" denial. From your letter:"A denial described as "global" means that a procedure performed by the provider was broken down into separate charges when only one charge should have been submitted. For example, a charge for an injection usually includes the cost of administering that injection. Providers may, from time to time, break down the injection and submit separate charges for each component of the procedure, and this is typically disallowed."
I cannot find this definition in the plan. I have read, and reread, the Eligible Expenses, and Generally Excluded Charges definitions and their appropriate sections. I cannot convolute any of those provisions to even remotely allow the term "global".
Your "global" denial seems to converge on a combination of the medication(s), venipuncture, and the administration.a. The treatment needs the medication.
b. The treatment requires a syringe and other supplies.
c. The treatment requires delivery (venipuncture).
d. The treatment requires administration by skilled medical personnel.
e. Each component possesses a separate CPT code, and is an eligible expense for reimbursement.
Are you saying that all the charges should be rolled up into a single submitted charge? Would this rolled-up line item possess an identifiable CPT code? Or would it require the breakdown already submitted for reimbursement as "documentation required to establish medical necessity"? You can't have it both ways.
I find your usage of "global" to be akin to refusing to pay for the oil filter and the mechanic's time, since you only asked an oil change. Yes, they present you with a universal oil change charge, but for other inventory and cost containment procedures, the invoice will list each component and the price. The bottom line remains the same, it takes every component to perform the job.
Please provide me with the Plan provision(s) that supports your "global" denial. I'm willing to be educated; I am not willing to be defrauded.
I must also address the "duplicate charges" denials. In your November 5, 1998 letter, you state:"For example, if a claim has been denied for duplicate charges, that means that the provider submitted the same claim twice."
Haven't you ever received a second, third, and fourth billing notice because you ignored the first one? Your spreadsheet did not address the ORIGINAL claim, or its disposition. Please provide the disposition of the ORIGINAL claim. Then, and only then, can the Duplicate Charges denials be put in their proper prospective. It will also allow us to address any denials of the ORIGINAL submission.
An additional point of interest covers arbitrary and inconsistent PPO discounts. An analysis of the spreadsheet shows that identical procedures and supplies received different "adjustment" levels. Since the PPO discounts are a matter of the contract between you and the provider, I cannot really take personal issue with them. However, they do reinforce the observation that FIRST HEALTH seemingly does not provide a consistent level of service when evaluating and administering claims.
Ms. Farina seems to maintain a high level of reliance on your office to do the right thing, rather than exercise her discretionary judgment to make a final decision or direct you to do the right and proper thing.
From my point of view, that reliance is ill founded. Your administration of the Plan is in direct contradiction of the language of the Plan. It has led to a needless disability, and on February 15, 1999, the loss of my job.
Your denial history is solely responsible for blocking my access to the health care that could return me to a productive state of life. My provider's treatment to date has been consistent with all accepted practices and in line with peer reviewed literature. Yet your erroneous denials have created a monetary level of arrearage that cannot be absorbed by either the doctor nor my household. Nor should that arrearage be absorbed by either of us. They are expenses that are eligible for reimbursement by the Plan, which you ( FIRST HEALTH ) have the legal and moral requirement to perform.
Put simply, no physician would, or should, undertake the more aggressive (and costly) treatment protocols when the issue of payment is in doubt. When your administration of the Plan creates a five-figure level of unpaid bills, it most assuredly blocks access to health care. This blockage directly attributes to mental, physical, and economic harm.
From an initial diagnosis of Lyme Disease; easily although not inexpensively treatable, your non-payment has led to the progressively debilitating addition of:
Please, please, clear the arrearage that is blocking my access to health care; guarantee the recommended IV antibiotic treatment. Let me get well.
Begging,
R. James Martin
cc:
