Battery Replacement Surgery Versus the Insurance Scoring Algorithms – Law Suit
Posted Nov 23 2009 10:01pm
This is somewhat interesting as the algorithms calculated here went past the marks allowed for the patient’s healthcare coverage. She had the original implant in 2005, batteries replaced in 2007 and now needs them again. Blue Cross paid for the other 2 surgeries and now calls this one experimental? If they paid once for batteries how can it be experimental?
It sounds more to me like some algorithms were run and it was determined that she had possibly exceeded the amount they figure with business intelligence software to be allowed. Now the case goes to court and will cost everyone a lot more. This runs into one of those areas where the algorithms are getting in the way of what is morally correct. Why not ask Medtronic to kick in here too, or the insurer could at least ask and find out what improvements have been made or if there is a longer lasting battery available at this time, maybe? BD
Plaintiff Paige Riley, 42, is an extreme example of what can happen as a result. She alleges that Blue Cross & Blue Shield of Mississippi refused to cover an operation to replace the batteries of a stomach-pain device she had surgically implanted in 2005. As a result, Riley had to fork over the $43,364.27 cost in cash.
Riley suffers from gastroparesis, a nasty condition in which the stomach cannot empty itself, causing nausea, vomiting and pain. According to the lawsuit, in 2005 she got a new device from Medtronic ( MDT - news - people ) implanted in her stomach that uses mild electric pulses help relieve symptoms. Called the Enterra, it was approved in 2000 under the FDA's humanitarian device exemption, which is for devices that target a very narrow group of patients.
Her husband's employer, Electric Power Association, covered the first operation and a second operation to put in new batteries in 2007. But by the time Riley needed a third operation to get another set of batteries this spring, Blue Cross & Blue Shield of Mississippi was the plan administrator for the Power Association. It ruled that the Enterra was experimental and refused to cover the new batteries, the lawsuit says. Appeals were denied, according to the lawsuit filed in federal district court in Jackson, Mississippi on Nov. 10.