STATE OF MICHIGAN DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION

Transcription

1 In the matter of STATE OF MICHIGAN DEPARTMENT OF ENERGY, LABOR & ECONOMIC GROWTH OFFICE OF FINANCIAL AND INSURANCE REGULATION Before the Commissioner of Financial and Insurance Regulation XXXXX Petitioner File No v Consumers Life Insurance Company Respondent / Issued and entered this 30th day of September 2010 by Ken Ross Commissioner ORDER I PROCEDURAL BACKGROUND On June 23, 2010, XXXXX, authorized representative for her son XXXXX (Petitioner), filed a request for external review with the Commissioner of Financial and Insurance Regulation under the Patient s Right to Independent Review Act (PRIRA), MCL et seq. The Commissioner notified Consumers Life Insurance Company (Consumers Life) of the external review and requested the information used in making its adverse determination. The Office of Financial and Insurance Regulation received the information from Consumers Life on June 24, The Commissioner reviewed the information and accepted the request on June 30, The case involves medical issues so the Commissioner assigned the matter to an independent review organization, which completed its review and sent its recommendation to the Commissioner on July 14, II FACTUAL BACKGROUND

2 Page 2 Petitioner is covered under a Consumers Life major medical policy titled Michigan Individual Product 500/100 w/superscript. The Petitioner is 19 years old. In 2005, he suffered a herniated disc in his lower back. He has tried physical therapy to remedy his pain but it has continued. In late 2008, he was ready to try steroid shots. To assist the doctor in locating the injured area to administer the steroid injections, Petitioner had an MRI of the lumbar spine. Consumers Life denied coverage on the basis that the MRI was not medically necessary. Petitioner appealed Consumers Life s denial of coverage for the MRI through Consumers Life s internal grievance process. Consumers Life maintained its denial and issued a final adverse determination dated June 11, 2010, affirming its denial. III ISSUE Did Consumers Life correctly process the claim for Petitioner s MRI? Petitioner s Argument IV ANALYSIS Petitioner s physician, Dr. XXXXX, M.D., wrote a letter on November 10, 2009, supporting his decision to order the MRI. Dr. XXXXX stated that he had last seen Petitioner on a clinical basis in July Petitioner s family contacted him in November 2008 and informed him that Petitioner s symptoms had changed significantly; he was experiencing back and leg pain. Dr. XXXXX wrote that Petitioner was not formally evaluated in his office immediately prior to ordering the MRI in question; he ordered the MRI without scheduling a separate office visit in an effort to minimize Petitioner s time away from school and so that Petitioner could avoid the 30 mile drive to his office. Dr. XXXXX and Petitioner believe Petitioner s lumbar MRI scan was medically necessary. Respondent s Argument In its June 11, 2010, final adverse determination, Consumers Life stated that the MRI did not meet the policy s criteria for medical necessity. The final adverse determination also indicated there

3 Page 3 was no documentation of a physical exam and/or any neurological symptoms, no x-ray results, no 4 to 6 week trial of anti-inflammatory medications, physical therapy or home exercise program, and activity modification. Commissioner s Review Consumers Life provides coverage for treatments listed in the policy which are medically necessary. The policy (page 39) defines medically necessary as: a service, supply and/or Prescription Drug that is required to diagnose or treat a Condition and which Consumers Life determines is: appropriate with regard to the standards of good medical practice and not Experimental or Investigational; not primarily for your convenience or the convenience of a Provider; and the most appropriate supply or level of service which can be safely provided to you.... The question of whether Petitioner s lumbar MRI was medically necessary was presented by the Commissioner to an independent medical organization (IRO) for analysis. The IRO reviewer is a physician in active practice that has been published in peer reviewed literature. The reviewer is certified by the American Board of Neurological Surgery and is a member of the American Association of Neurological Surgeons, the Congress of Neurological Surgeons, and the AANS/CNS Joint Section on Pediatric Neurosurgery. The IRO reviewer s analysis and conclusions are reported below: Medical necessity is not demonstrated by the submitted documentation for a repeat MRI of the lumbar spine. The [Petitioner] did not have any known red flag conditions, such as suspected tumor, infection, or history of significant trauma. * * * The Milliman Care Guidelines detail the following indications for this clinical scenario: Lumbar spine magnetic resonance imaging (MRI) may be indicated for 1 or more of the following: Low back pain or radicular pain and Low back pain or radicular pain and ALL of the following: Patient failing to improve after 6 weeks of nonoperative treatment; examples include:

4 Page 4 Analgesics and nonsteroidal anti-inflammatory drugs Modification of activity that exacerbates or produces symptoms Advice to remain active, and bedrest discouraged Physical therapy Significant interference with daily function Patient being considered for invasive treatment (eg, epidural steroids, surgery) Acute, severe, disabling back pain unresponsive to high-dose analgestics Thus, when considering this case, the criteria for the Lumbar Spine MRI in question are not satisfied. The standard of care would not call for an MRI in this clinical scenario. The denial issued by Consumers Life Insurance Company for the lumbar MRI rendered November 10, 2008 was appropriate and in keeping with the standards of care in the community and should be upheld. Recommendation: It is the recommendation of this reviewer that the denial issued by Consumers Life Insurance Company for the lumbar MRI rendered on November 10, 2008 be upheld. The Commissioner is not required in all instances to accept the IRO s recommendation. However, a recommendation from the IRO is afforded deference by the Commissioner. In a decision to uphold or reverse an adverse determination, the Commissioner must cite the principal reason or reasons why the Commissioner did not follow the assigned independent review organization s recommendation. MCL (16)(b). The IRO s analysis is based on extensive experience, expertise and professional judgment. The Commissioner can discern no reason why the IRO s recommendation should be rejected in the present case. The Commissioner accepts the IRO reviewer s recommendation and finds that the Consumers Life denial of coverage for Petitioner s November 10, 2008, MRI was correct under the terms of the policy. V ORDER The Commissioner upholds Consumers Life Insurance Company s June 11, 2010, final adverse determination. Consumers Life is not required to provide coverage for the November 10,

5 Page , MRI. This is a final decision of an administrative agency. Under MCL , any person aggrieved by this Order may seek judicial review no later than sixty days from the date of this Order in the circuit court for the county where the covered person resides or in the circuit court of Ingham County. A copy of the petition for judicial review should be sent to the Commissioner of the Office of Financial and Insurance Regulation, Health Plans Division, Post Office Box 30220, Lansing, MI