Another lawsuit has been filed against Aetna Life Insurance, arguing that the insurer improperly limits coverage for lumbar artificial disc replacement by treating the procedures as experimental and investigational.
1. Aetna uses a clinical policy bulletin — a written directive on coverage positions the insurer considers for certain medical treatments — called "intervertebral disc prostheses" when deciding claims for lumbar ADR.
2. The insurer has "systematically denied all requests" for lumbar ADR as "experimental and investigational" under the policy, according to the lawsuit filed March 4 in the U.S. District Court for the Central District of California.
3. Contrary to Aetna's stance, lumbar ADR was approved by the FDA more than 15 years ago and is considered a safe and effective procedure for lumbar disc disease.
4. Plaintiff Andrew Howard suffered from disc disease at L5-S1 that caused significant pain and mobility and conservative measures such as medication and corrective exercises did not provide adequate relief, according to court documents. Robert Bray Jr., MD, recommended Mr. Howard undergo lumbar ADR, but Aetna denied the request and the patient had to pay for the procedures out of his own pocket.
5. The plaintiff argues that Aetna didn't cover the spine procedure that should have been covered under the Employee Retirement Income Security Act, designed to provide protections to as well as setting rules for employer-sponsored health insurance plans.
6. Aetna is also facing a 239-person class-action suit from 2019 related to its alleged denial of lumbar ADR.