Editor's note: You've tried to handle a dispute with your health plan on your own, but they won't budge. Is there anyone who can give you a straight answer? Well, it turns out that the state of California employs attorneys, nurses and analysts in the Department of Managed Health Care's Help Center to solve problems with your managed care coverage. They offer assistance with issues ranging from difficulties in getting an appointment to getting timely referrals to specialists, from denial of a doctor's recommendation for treatment or medication to an incorrect medical bill.
When my daughter was born, she was very small, and her weight never really caught up to where it should be. She's now 5 years old and was recently diagnosed with Turner's Syndrome, the most frequent chromosomal disorder in females. It results in a reduced adult height and an increased risk for other problems like diabetes, thyroid disorders and cardiac problems. Our doctor prescribed a growth hormone called Genotropin because it's been shown to significantly improve height. But Health Net refuses to pay for it because its medical director doesn't think it is medically necessary.
– Ray LaBay, Orangevale
Doctors sometimes prescribe medications or treatment plans that health plans then refuse to cover. The health plan will usually say the patient and their doctor should decide whether to proceed, but that doesn't mean the health plan will pay for it.
Whenever a health plan member receives a denial, they should ask the health plan to provide written notification that includes an explanation.
If the denial states that the contract does not cover the requested treatment or medication, it is called a coverage or benefit dispute. Plan members should consult the booklet they received upon enrolling with the health plan, the so-called Evidence of Coverage or Summary of Benefits, to verify that the requested treatment is not listed.
This is not the case for you, though. Health Net is denying your claim based upon "medical necessity."
That makes you eligible for an independent medical review. (Members also may be eligible for such a review if a claim is denied because the requested treatment is considered "experimental" or "investigational.")
The Department of Managed Health Care submitted your complaint to an independent doctor to decide whether Genotropin is medically necessary.
The reviewer found that the FDA has approved growth hormone therapy for patients with Turner's Syndrome and that medical trials have shown that patients who took Genotropin benefitted by increased adult height.
As a result, the independent reviewer overturned Health Net's denial and ordered that Health Net cover the medication for your family.
To ask a question of the Department of Managed Health Care, go to www.sacbee.com/ask or write Second Opinion; Features Department; The Sacramento Bee, P.O. Box 15779, Sacramento, CA 95852.
