A Recent Appeal Decision Out of The United States Court of Appeals for The Fourth Circuit Sheds Light on Several Missteps Made by an Employee Retirement Income Security Act (ERISA) Plan

A recent appeal decision out of the United States Court of Appeals for the Fourth Circuit sheds light on several missteps made by an Employee Retirement Income Security Act (ERISA) plan in denying coverage of medically necessary services.

A patient who underwent spinal surgery filed suit under the Employee Retirement Income Security Act (ERISA), 29 U.S.C. § 1001 et seq., after the insurance carrier, Central States, denied the claim for benefits following spinal surgery. The district court granted summary judgment to the patient, concluding that Central States had abused its discretion by relying on a physician’s review of the patient’s surgery that took place without the benefit of relevant medical records.

The plan’s physician who did the initial independent medical review denied the claim based on an incomplete medical record provided to him by the payer. After appeal, the denial was upheld by a second review for lack of a trial of conservative treatment, which was not a requirement of the plan. And, in fact, the patient did have conservative treatments which was ignored by the second reviewer.

The decision from the court concluded that the patient’s claim review by the plan did not follow a “reasoned and principled decision-making process.” The plan did not handle the patient’s claim in a “sensitive and fair-minded manner.”

This decision is a very interesting read and will remind you of why we do this important work of appealing claim denials on behalf of hospitals and the patients they serve. You can read the decision here.

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Denise serves as the Senior Vice President at Denial Research Group – AppealMasters. Denise is also President of The Association for Healthcare Denial and Appeal Management. Denise is a Registered Respiratory Therapist, Registered Nurse, and holds a Master’s degree in Management Information Systems from the University of Illinois, Springfield.

Denise has over thirty years of experience in healthcare, including clinical management, education, compliance, and appeal writing. Denise has extensive experience as a Medical Appeals Expert and has personally managed hundreds of Medicare, Managed Medicare, and Commercial appeal cases and presented hundreds of cases at the Administrative Law Judge level.

Denise is a nationally known speaker and dynamic educator on Medicare and Commercial appeals processes, payer behaviors, standards of care, appeal template development, and building a road map to drive the payer to a decision in the provider’s favor. She has educated thousands of healthcare professionals around the country in successfully overturning medical care denials.