Two people who suffered from limb loss and who were covered by Anthem health insurance company sued the company because it failed to provide certain prostheses. The company labeled microprocessor-controlled knee and foot-ankle prostheses as “investigational” and refused to provide coverage.
As of the time of filing the lawsuit, the company labeled all microprocessor-controlled foot-ankle prostheses as “investigational and not medically necessary for all indications. Under the terms of the insurance policies issued, the company is not responsible for paying for medical devices and treatments that are investigational.
The company labels “investigational” services as services that meet one of seven criteria: 1. Services that are not generally accepted as proven or effective procedures within the organized medical community; 2. Services that do not have final approval from the appropriate governmental regulatory body; 3. Services that are not supported by scientific evidence which permits conclusions concerning the effect of the service, drugs, or device on health outcomes; 4. Services that do not improve the health outcome of the patient treated; 5. Services that are not as beneficial as any established alternative; 6. Services whose results outside the investigational setting cannot be demonstrated or duplicated; or 7. Services that are not generally approved or used by doctors in the medical community.
If you have had a claim for a prosthesis denied by Anthem, call me, Conal Doyle, Los Angeles personal injury attorney, at 310-385-0567. Our team is working on the lawsuit, and we are seeking additional plaintiffs. Call to learn more or to schedule a free consultation.