Ledes from the Land of Enchantment

Medicaid Patient Alleges Blue Cross Stalled Pancreas Treatment – InsuranceNewsNet

Apr. 21—A Bernalillo County woman alleges in a Blue Cross Blue Shield of New Mexico lawsuit repeatedly denied her requests for coverage as a tactic to discourage her from pursuing treatment outside the state for a painful and debilitating pancreatic condition.At a final hearing in front of a state agency Dec. 30, 2020, Blue Cross agreed to cover a complex treatment option in Virginia, the suit says.

Although approval for the procedure finally was granted, says the complaint, filed last month in the First Judicial District Court on behalf of Medicaid patient Julie Graham, Blue Cross breached its contract, violated the insurance code and should pay punitive damages and attorney’s fees.

The lawsuit alleges there are other situations like this involving Blue Cross, although it doesn’t state how many.

Attorney Pierre Levy of Santa Fe declined Monday to discuss other possible examples.

Graham also declined to comment, although Levy said she planned to speak about her case later this month.

Besides arguing the delays were strategic, the suit also contends the two doctors who weighed in for Blue Cross weren’t experts in Graham’s disease and weren’t equipped to render an opinion.

The program in question is Blue Cross Community Centennial, which is the insurer’s program for Medicaid. Blue Cross is one of several insurers that contract with the state to provide Medicaid, a state and federal program for people with limited resources.

The suit alleges Blue Cross “engages in a pattern and practice of discouraging claimants, and of denial and delay of care, to increase its profits.”

A Blue Cross spokeswoman declined to comment on the lawsuit but wrote in an email, “Blue Cross and Blue Shield of New Mexico … is truly privileged to serve our valued Medicaid members by helping them access the many services offered by our state’s Medicaid Managed Care program.”

Graham’s lawsuit says she had to be hospitalized numerous times in 2019 and 2020 because of pain from her pancreatic disorder.

She lost three jobs because she couldn’t work consistently and lost 25 pounds during her battle with the disease, she claims.

Graham, a registered nurse, also went on parenteral nutrition, which is given through a vein to bypass eating and digesting, the suit says.

Physicians at the University of New Mexico found she needed to have her pancreas removed, and then have clusters of cells called islets taken from the pancreas and infused into her liver.

A doctor referred her to Virginia Commonwealth University, where a physician is an expert in the procedure, the suit says.

But, it adds, Blue Cross found the case didn’t meet “clinical criteria.”

According to the suit, Graham’s denial of the treatment from Blue Cross said, “You have a bad pancreas. You have trouble digesting your food. You have lost weight. Medications can only help you so much.

“You may need surgery. It needs to be done in a hospital. However this hospital [the one in Virginia] is not part of your health plan. We cannot approve you to see providers that are not part of your health plan unless it is an emergency. Your doctors notes do not say that this is an emergency. We are denying the request.”

At various stages in the effort, two Blue Cross doctors recommended Graham get treated in New Mexico, Texas or at the University of Colorado, but the suit says the procedure wasn’t available in those places.

Graham persisted in her appeals, and the state Office of Fair Hearings scheduled a telephone hearing Dec. 30, 2020. Graham says in her suit she participated from a hospital bed.

Shortly after the hearing convened, the suit says, Blue Cross representatives requested a brief recess and “agreed to provide authorization to Plaintiff Graham for the … procedure to be performed” at Virginia Commonwealth University Health Systems.”

Graham’s Facebook page says she had the procedure early last year.


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