The Latest from the Front Lines: Continuing Our Insurance Discussions

Part of our ongoing series of discussions with patients regarding the Medical Insurance Industry and our efforts to help ensure as much reimbursement as possible for individuals

This October, the Institute for Nerve Medicine’s medical director Dr. Aaron G. Filler, MD PhD FRCS attended the national meeting for the Congress of Neurological Surgeons in Chicago. This is an annual event in which board certified neurosurgeons meet to discuss healthcare standards in their field. Dr. Filler also is a member of the Peripheral Nerve task force committee, where he and his peers discussed the recent negative impact of insurance plans. The task force is committed to changing the insurance plans’ recommendations from a focus of what makes the plan money to a focus of what is in the best interest of the patient.

Major plans such as Blue Cross and Aetna are appointing non-specialty, non-certified doctors, nurses and other industry-paid medical consultants to render medical policy determinations based on fiscal models and outdated medical research. The confusing assignments of “not medically necessary” or “experimental treatment” and even “beyond the usual and customary” cause patients to have to pay out of pocket for any medical service given these labels by their insurance plan. Naturally, many patients choose to refuse medical services that are beneficial to them, simply because their insurance plan will not cover the service. But the fact is that these services actually are medically necessary, they have peer and clinical support and they exceed the standards of care which are all good things for patients seeking quality medical services.

So why would an insurance plan state that a medical service is experimental and not medically necessary even though they can see that standard testing such as EMG has failed to resolve diagnostic complexities? Because the insurance plan is relying on flawed logic, applying criteria for drug therapy as a medical standard for clinical therapy, as a cost savings measure for denying benefits for members. Here is why the policy does not make sense — and some guidance on what you can do about it.

There are several objective medical publications and studies to support the use of MR Neurography. In fact, the major chief medical textbook requires the use of MR Neurography as part of meeting the standard of care for complex spine and peripheral nerve conditions. Large scale, double blinded randomized trials are appropriate for evaluating new medications for common conditions, but insurance companies instead often rely on a drug trial study as a reason for labeling MR Neurography as experimental. Simply put, this is inappropriate for decision making for a rare medical condition.

The purpose of a randomized trial is to simulate drug efficacy by applying two different treatments to the same individual in order to learn which treatment is more effective. This requires several conditions that are not applicable to patients who are seeking MR Neurography scans for unique pain conditions related to soft tissue injury, complex spine and peripheral nerves.

For this type of study to make sense, you would first have to experience a homogenous and readily identifiable condition to treat. For instance, consider the case of a particular type of diabetes. This serves as the mental model for many studies because we have a very well understood biochemical defect which allows for a large study group and very easily measured indices. When we have two drug treatments wherein both are thought to have good efficacy and wherein we wish to learn which is more efficacious, there is no ethical problem with randomizing patients to either drug trial. This is because we have no proof that either group is disadvantaged.

In the matter of MR Neurography, we have the fact that patients being evaluated for pain conditions related to spine and soft tissue injury are inherently non-homogenous and a disparate group. It would be virtually impossible to find patients with the exact same nerve, spine, and anatomical conditions for randomized trials and if you were even able to find a group, then the actual treatment therapies would have to be identical for each person. This is an impossibility. You cannot have doctors and surgeons doing injections and spine surgeries on a living human being when the doctor is somehow blinded to whether or not his procedures are actually being done as he does them.

Absent double blind studies, the insurance ban on advanced techniques such as MR Neurography and Open Guided MRI injections is essentially meritless. We are looking at a new technology when there is no existing gold standard for treatment planning. EMG, standard MRI, ultrasound and CT scans have lesser imaging quality and lesser successful outcomes. If there is an existing gold standard that can reliably and correctly diagnose these spine and soft tissue conditions, then why are there a large percentage of unresolved spine and nerve conditions?

Patients who have arbitrary plan limits are encouraged to appeal for benefit coverage of medical services. Especially if the patient has exhausted in network resources for treatment, then they should not be discouraged by the insurance plan’s mistake in policy. Instead, patient should appeal for authorization and coverage for medical services that are endorsed by the Congress of Neurological Surgeons and not by an insurance administrator or paid medical consultant. Ask yourself and then ask your insurance plan, if the in network plan recommendations are just as clinically effective as newer advances, then WHY are you still uncertain of treatment and experiencing unresolved pain symptoms?

All the team members of the Institute for Nerve Medicine are here to help you with your appeals process. For more information, please email us at or call us at 866-41-NERVES between 9AM-5PM Monday-Friday Pacific.