Patient sues Blue Shield of California over denied artificial disc replacement: 5 key notes

Written by Laura Dyrda | September 21, 2015 | Print  |

A patient who underwent artificial cervical disc replacement surgery is suing Blue Shield of California for refusing to cover the procedure, according to a Courthouse News report.

Here are five key notes on the case:


1. Blue Shield of California considers artificial cervical disc replacement investigational and doesn't cover the procedure, although several discs have FDA clearance and the procedure achieved a Category I CPT code earlier this year. The surgery is also common in Europe and has been approved in the United States for 10 years.


2. The plaintiff, Jeff Bush, hurt his neck in August 2014 and an orthopedic surgeon recommended artificial disc replacement. At that time, Blue Shield of California refused to pay based on the lack of long term efficacy and safety when compared with spinal fusion.


3. In his lawsuit, Mr. Bush alleges the refusal to cover artificial disc replacement surgery breaches Blue Shield of California's duty as a fiduciary of an ERISA health plan because there is "valid scientific evidence" to support disc replacement procedures.


4. Mr. Bush asked for clarification of rights under the Blue Shield plan as well as damages for breach of fiduciary duty and an injunction that would force Blue Shield to retract artificial disc replacement as investigational. He also asks the insurer to review denied claim, according to the report.


5. Robert Gianelli with Gianelli & Morris is representing Mr. Bush. Blue Shield of California did not comment on the suit for this article.


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