[Avera Law Firm] Changing the Mind of the Health Insurance Company

[Mark Avera]

On September 25, 2009, a sixty-three (63) year old happily married man, father of four and grandfather to thirteen grandchildren, and senior pastor at a church, was referred to Avera & Smith because he was suffering from stage IIB malignant melanoma of the left cheek which subsequently developed into metastatic disease to the left upper lobe of his lung and he needed help. When our client appeared in our office he had been given a very short period of time to live if he did not receive treatment for the metastatic disease. His only course of treatment, at this time, was Cyberknife radiosurgical management of the two lesions; however, his health insurance provider, Blue Cross Blue Shield was denying the coverage necessary to pay for this procedure.
His coverage was denied because Blue Cross Blue Shield’s doctors believed the procedure was investigational. The company made this finding even after being advised by our client’s treating oncologists that the procedure was not investigational and was his only viable option because the client had already undergone a partial left lobectomy in April 2009 which revealed a 2-cm metastatic deposit of malignant melanoma, and he subsequently developed additional pulmonary nodules, one in the right middle lobe and an additional nodule in the left upper lobe, for which he was treated with three (3) cycles of chemotherapy. This treatment was ineffective and during a follow up evaluation of his response to this therapy, it was found that the right middle lobe nodule had increased from 8mm to 12 mm and there was an increase in the left upper lobe nodule from 6mm to 12 mm.
The procedure was also denied after Blue Cross Blue Shield approved and provided coverage for the placement of a fiducial marker in his right lung for purpose of performing the Cyberknife treatment.
Tina Seifert of Avera & Smith became involved in this matter and was able to successfully and quickly convince Blue Cross Blue Shield to re-evaluate the denial of this coverage and finally succeeded in getting the company to approve and pay for our client’s treatment. We are very proud of quickly convincing BCBS that they were wrong.
Indeed, regardless of where you are in the healthcare debate, you should know that “bureaucratic” decisions are arbitrarily made everyday that affect the lives of hard working Americans. Whether made by a corporation or government, it’s wrong and should never be tolerated in our healthcare system.

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Posted By Mark Avera to Avera Law Firm at 10/13/2009 10:55:00 AM