My friend, Zoë Keating, is a musician, wife and mother. Recently, her husband was diagnosed with stage 4 lung cancer. He is Vegan, and has never smoked anything in his life.
On May 13 an MRI found 20 tumors in my husbands brain. On May 15 he could barely breathe and was in a lot of pain. A CT scan that day revealed he had a softball-sized tumor in his lung, tumors in his other lung, his liver and possibly his bones. On our way home from the imaging center our primary care doc called and told us to turn around and get to the hospital right away. My husband was admitted and they promptly removed more than a pint of fluid from his lungs, which helped him breathe better. We were there for 6 days while they performed a bronchoscopy, did more scans, gave him drugs to stop his brain from swelling and administered emergency chemo.
Zoë and Jeff submitted their claim to their health insurance provider, Anthem Blue Cross. Their claim was reviewed by an OB-GYN instead of an Oncologist for some reason, and that person decided to deny their claim:
"Coverage for the requested service is denied because the service does not meet the criteria for “medical necessity” under your description of benefits. To assist our Medical Director in making this decision, we have put a process in place to send all information about the service to a clinical reviewer with appropriate credentials. Based on their opinion, we have determined that covered for the requested service is denied. Our Medical Reviewer Layma Jarjour MD has determined we cannot approve your hospital stay for cancer. We do not have enough facts to show that it was medically necessary. "
Jeff was admitted to the hospital because he had cancerous tumors all over his fucking body, his lungs were filling with fluid, and if he was not admitted, he. Would. Die.
For some reason, Medical Reviewer Layma Jarjour MD decided that this was not "medically necessary."
If putting someone into the hospital to save their life because their lungs are filling with fluid and that person will die if they are not treated immediately is not "medically necessary", what is?!
Zoë pointed out that "Anthem is owned by WellPoint. Did you know Wellpoint CEO Joseph Swedish earned almost $17 million during his first year on the job? Now you know how they can afford to pay him."
I hope that, by shining some light on this, Anthem Blue Cross will reverse its decision, and honor their claim. They are suffering enough right now, and don't need this crap.