v File No Aetna Life Insurance Company Respondent Issued and entered this 5 th day of December 2011 by R. Kevin Clinton Commissioner

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1 In the matter of XXXXX Petitioner STATE OF MICHIGAN DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS OFFICE OF FINANCIAL AND INSURANCE REGULATION Before the Commissioner of Financial and Insurance Regulation v File No Aetna Life Insurance Company Respondent Issued and entered this 5 th day of December 2011 by R. Kevin Clinton Commissioner ORDER I. PROCEDURAL BACKGROUND On June 29, 2011, XXXXX (Petitioner) filed a request for an expedited external review with the Commissioner of Financial and Insurance Regulation under the Patient s Right to Independent Review Act, MCL et seq. In order to receive an expedited external review under PRIRA, a physician must substantiate that the Petitioner s life or health would be seriously jeopardized or the Petitioner s ability to regain maximum function would be jeopardized if an expedited review is not granted. In this case, a physician has not documented such conditions. Therefore, the Commissioner has determined that the issues in this case do not merit prompt resolution and this external review could be completed within normal time limits provided in PRIRA. On July 7, 2011, after a preliminary review of the material submitted, the Commissioner accepted the request for external review on a non-expedited basis. The Petitioner receives health benefits through a Benefit Plan (the certificate) underwritten by Aetna Life Insurance Company (Aetna). Because medical issues are involved, the Commissioner assigned the case to an independent review organization which provided its analysis and recommendations to the Commissioner on July 21, 2011.

2 Page 2 II. FACTUAL BACKGROUND The Petitioner has a history of right knee pain. She sought treatment from an orthopedic surgeon who recommended she have an MRI to diagnose the cause of her pain. Aetna apparently required that the Petitioner receive physical therapy before it would provide coverage for an MRI. From October 14 to November 11, 2010, the Petitioner had physical therapy for which Aetna provided coverage, applying the Petitioner s deductible then paying 80% of covered expenses. After the completion of the physical therapy, Aetna initially denied coverage for the MRI Petitioner received on November 24, Coverage for the MRI was provided after the Petitioner challenged the denial through Aetna s internal grievance process. Petitioner appealed through Aetna s internal grievance process asking for 100% coverage of the physical therapy. Aetna maintained its determination and issued its final adverse determination dated June 1, III. ISSUES 1. Did Aetna correctly require Petitioner to undergo physical therapy as a condition to receiving an MRI? 2. Did Aetna correctly deny 100% coverage for the physical therapy Petitioner received from October 14, 2010 through November 11, 2010? Petitioner s Argument IV. ANALYSIS In her request for external review, Petitioner wrote: I was forced into receiving PT by Aetna Insurance in order to have an MRI taken of my knee. The doctor, PT and PTA all knew there was serious internal damage already present that would not be repaired with therapy. However, this was the only way to get the initially prescribed MRI. In a clinic note dated August 2, 2010, Petitioner s orthopedic surgeon wrote: Patient presents to the orthopedic clinic today in follow-up of her right knee. She was last seen on 07/14/10 where she was evaluated for possible internal derangement of her right knee. At that time I recommended she get an MRI. The MRI, however, was refused by her insurance company. The patient at this point will try an appeal process through her insurance company to obtain the MRI. She

3 Page 3 has been taking naproxen 400mg in the morning and 400mg at night with food. Her effusion has subsided. She does have some resolution of her pain; however, it is not completely gone. This, coupled with her longstanding history of right knee pain, still indicates that there could be possible internal derangement of the right knee. Respondent s Argument In its final adverse determination dated June 1, 2011, Aetna wrote: This appeal is about the following issues: The amount applied to the deductible for the physical therapy services from October 14, 2010 through November 11, 2010 provided by XXXXX. The denial of the Magnetic Resonance Imaging on November 24, 2010 provided by XXXXX. * * * [W]e are upholding the previous decision reprocess [sic] the amount applied toward the deductible for the physical therapy services from October 14, 2010 through November 11, 2010 provided by XXXXX. However, we will allow coverage according to your plan benefit for the Magnetic Resonance Imaging on November 24, 2010 provided by XXXXX. * * * We have authorized the Magnetic Resonance Imaging, since conservative treatment was provided. Commissioner s Review The certificate provides coverage for short-term outpatient therapy at the following levels: for network providers, 80% per visit after the calendar year deductible has been satisfied; for out-of-network providers 60% per visit after the calendar year deductible has been satisfied. Aetna processed the Petitioner s therapy at the 80% level which was the correct application of the terms of the certificate. The Petitioner asserts that it was not appropriate for Aetna to require her to have physical therapy prior to undergoing an MRI. This question was presented by the Commissioner to an independent medical review organization (IRO) for analysis as required by section 11(6) of the Patient s Right to Independent Review Act, MCL (6). The IRO reviewer is a physician who has been in active practice for more than 15 years and is board certified in physical medicine and rehabilitation. The reviewer is familiar with the medical management of patients with the Petitioner s condition. The IRO reviewer provided the following analysis and conclusion:

4 Page 4 [T]he member received physical therapy for treatment of knee pain and a possible meniscal tear. [T]he member received physical therapy with some improvement in range of motion and strength. [T]he physical therapy that the member received from 10/14/10 to 11/11/10 was a medically necessary and appropriate treatment for her. [T]he member clearly had some injury to her right knee, which was possibly an internal injury due to potential degenerative changes and there was an expectation of some improvement going forward. [T]he fact that the member had minimal improvement is not material to the issue of whether the physical therapy was medically necessary. [A] trial of arthroscopic versus supervised therapy for medial meniscus tears concluded that menisectomy was not superior to supervised exercise. [Citation omitted] [A] trial of conservative therapy, including medications and physical therapy, is standard of practice for treatment of possible degenerative tears of menisci in the knee before consideration of surgical treatment. The Commissioner is not required in all instances to accept the IRO s recommendation. However, the IRO recommendation 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, and is supported by literature. The Commissioner can discern no reason why the IRO s recommendation should be rejected in the present case. The Commissioner finds: 1) Aetna s requirement that the Petitioner undergo physical therapy prior to undergoing an MRI is consistent with the certificate of coverage and the standard of care for treatment of Petitioner s condition; and 2) Aetna s denial of 100% payment for Petitioner s physical therapy was appropriate under the certificate and schedule of benefits. V. ORDER The Commissioner upholds Aetna Life Insurance Company s final adverse determination of June 1, Aetna is not responsible for 100% coverage for the physical therapy Petitioner received from October 14 through November 11, This is a final decision of an administrative agency. Under MCL , any person aggrieved by this Order may seek judicial review no later than 60 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 Financial and Insurance Regulation, Health Plans Division, Post Office Box 30220, Lansing, MI

5 Page 5 R. Kevin Clinton Commissioner