A 62-year-old Oregon kindergarten teacher has sued Moda Health and EviCore Healthcare, alleging the companies denied coverage for her cervical spine surgery solely because she was older than 60.
Patricia Jenson filed the proposed class action Nov. 3 in Multnomah County (Ore.) Circuit Court. She is seeking up to $15.05 million in individual damages. The complaint also seeks classwide injunctive and declaratory relief for Moda’s non-ERISA members in Oregon who were denied care based on age since Nov. 1, 2020.
Ms. Devine Jenson was insured through the Oregon Educators Benefit Board. According to the complaint, Emily Nguyen, MD, an orthopedic spine surgeon, diagnosed her with a large disc extrusion at C6-7 that was causing severe stenosis and cord impingement. Dr. Nguyen recommended cervical disc arthroplasty instead of fusion.
Moda denied prior authorization July 10, citing EviCore’s guideline “CMM 602: Cervical Total Disc Arthroplasty.” That guideline limits the procedure to patients ages 18 to 60. The denial letter said, “There is an age limit for this service,” according to the complaint. The lawsuit alleges the Mobi-C implant Dr. Nguyen planned to use is FDA-approved for adults up to age 67.
Ms. Devine Jenson borrowed $29,731 from a family member to pay for the surgery out of pocket. Dr. Nguyen performed it July 17 at Northwest Ambulatory Surgery Center. The complaint says the procedure was successful and she returned to teaching for the new school year.
Three days after the surgery, Moda issued its final denial of her expedited appeal. The letter confirmed she met every medical necessity criterion except age, according to the complaint.
The lawsuit brings claims for breach of contract, negligence per se and age discrimination under Oregon’s public accommodations law. It also cites Oregon statutes that bar insurers from discriminating based on age. Ms. Devine Jenson said she plans to amend the complaint to seek punitive damages.
Becker’s has reached out to Moda Health and EviCore Healthcare and will update with any additional information.
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