Case number one involved a denial of coverage of sacral nerve stimulation for fecal incontinence. The plan (Employer: Kodak; TPA: MVP Health Plan) denied coverage on the ground that this allegedly is experimental investigational. The chosen IRO, MCMC, (1) did not send me a copy of their decision, but only sent it to the provider, and when I asked about this, they said they never send their decisions to anybody other than the member and the provider, even when the member is represented by counsel; (2) did not state the reviewer's credentials; and (3) did not list the materials they reviewed in conducting their review. The reviewer agreed with us that the service is not experimental/investigational. However, he made up an entirely new standard, claiming that the patient's fecal incontinence was not severe enough to warrant this treatment. Where this severity requirement comes from is anybody's guess. It certainly is not in the plan's coverage policy or in the FDA approval letter, or in any of the published medical literature. We could not help but feel that the reviewer was straining to do whatever needed to be done to find a reason to deny coverage.

Case number two involved a denial of IVIg for the treatment of a patient with normal IgG levels, but who has severe polysaccharide nonresponsiveness and recurrent infections. The plan (Employer: University of Chicago; TPA Blue Cross Blue Shield of Illinois) denied coverage on the ground that the patient did not meet the criteria for polysaccharide nonresponsiveness or recurrent infection. The plan relied on blood tests for a date certain; there were no blood tests for that date. There were at least fifty office notes documenting respiratory and sinus infections that were difficult to treat, always treated with antibiotics. At no time did the plan state why this documentation of recurrent infections was insufficient.

There also were several procedural irregularities. For example, no appeal instructions were provided with the denial. In addition, although the plan sent me a letter stating that we would have an opportunity for a hearing on the second level internal appeal, I called and called to schedule this hearing, then finally faxed a letter, to no avail - we never got our hearing. But most egregious of all, we filed our request for external appeal in July 2011. It was not until I started calling and calling that BCBS of IL finally told us in September that they did not see our appointment of representative form, so the appeal was just ignored. When I sent them the appointment of representative form again, they then said that they had logged our previous appeals in as provider appeals rather than member appeals, and so we had to exhaust the member's internal appeals before we were entitled to external review. Once I convinced them that the way they characterized the appeals was not an excuse to require us to file another two levels of internal appeal, they mistakenly sent the appeal to the state for assignment of an IRO. After an IRO was assigned, they realized their mistake, recalled the file from the state, and said they would assign their own IRO. They finally assigned the IRO, MCMC, in October - three months after we had filed the request for external review.

MCMC denied coverage. Again, they did not send me the decision; they sent it to my client only. Again, they did not provide the reviewer's qualifications. Again, they did not list the materials they reviewed. Although we had included a discussion of the procedural irregularities, MCMC did not comment on them at all. As regards polysaccharide nonresponsiveness, they essentially said that the treating physician's interpretation of the blood test results was just wrong. They did not explain why. They did not cite authority. They just said that the pneumococcal antibody titers were protective, whereas the treating physician says they were not. Then they said that, although BCBS of IL's policy requires only that we show that the titers were not increased at least four-fold after vaccination, the reviewer thought that wasn't a strict enough standard! As regards evidence of infections, the reviewer said we could not show recurrent upper respiratory or sinus infections without rhinoscopy, CT scan, and/or sputum cultures. The patient has had countless infections; not only did the plan never state in its coverage policy or denial letter that this type of proof is required, but it seems strange that the plan would want to pay for expensive tests every time a patient has sinusitis, nor does it make good medical sense to have the patient go through invasive procedures when every one of the three physicians treating this patient have diagnosed her infections consistently and repeatedly. Again, we cannot help but feel that this is a reviewer who is straining to find a way to rule for the plan.

Finally, in the third case, in which I merely assisted the consumer, the same IRO, MCMC, assigned a physiatrist with a specialty in pain management to a case in which a neuromuscular geneticist recommended physical therapy. The case had nothing to do with pain control. There is no question that this was the wrong type of specialist to assign to the case; however, MCMC and the TPA (Aetna) have rejected the consumer's request that the file be re-reviewed by a physician with the appropriate expertise. Further, the consumer only learned of the result of this expedited appeal by taking the initiative to call a week later; he was not notified of MCMC's decision.

Since MCMC is one of the largest IROs, we have had many external appeals involving fully-funded plans submitted to them over the years. Although I was not always happy with the result, MCMC was professional, it followed the rules, and it was thorough. That most definitely is not the case with respect to the external reviews they are conducting on behalf of self-funded plans.