Spine surgery patient prevails in payment denial suit against insurer

Laura Dyrda -  

A North Carolina woman's health plan was ordered to cover her spine surgery after a district court found the insurer failed to provide complete records to the reviewers who recommended coverage denial.

Dorothy Garner filed a lawsuit in the U.S. District Court for the Middle District of North Carolina against Central States, Southeast and Southwest Areas Health Plan and Welfare Fund Active Plan to cover the costs of her 2019 spine surgery. Central States refused to pay the bill after two reviewers deemed the surgery medically unnecessary.

Central States sent the initial reviewer, a board-certified general surgeon, some but not all of Ms. Garner's medical records. The reviewer concluded surgery wasn't medically necessary because he didn't receive an MRI showing significant myelopathy or radiculopathy or documentation of failed nonoperative treatment.

Ms. Garner had undergone an MRI and her surgeon did document failed nonoperative treatment, but Central States did not send those records to the reviewer, according to court records. The health plan also doesn't state the insured must attempt non-surgical options before surgery becomes medically necessary. Ms. Garner appealed Central States' decision.

Central States engaged a second reviewer, a board-certified neurosurgeon, to examine the case with full documentation. The neurosurgeon also recommended denial based on absence of abnormalities on the neurologic exam, among other issues.

In her decision, District Judge Catherine Eagles wrote the failure to provide independent reviewers with complete medical records resulted in a flawed process. She also concluded Central States left the term "medically unnecessary" undefined in its plan. Ms. Eagles said both factors entitled Ms. Garner to the full health insurance benefits covering her surgery in an April 27 memorandum.

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