Opinion ID: 788187
Heading Depth: 2
Heading Rank: 2

Heading: Reasonableness of Benefit Decision

Text: 15 Our record review convinces us that United HealthCare's decision to deny coverage is supported by substantial evidence and is, therefore, reasonable. The record indicates that, at the direction of Dr. Rea, Ortlieb commenced TPN treatment in late October 1999 and then sought coverage from United HealthCare. Upon receiving a request for TPN coverage, United HealthCare requested additional medical records, which were received in mid-November 1999. Dr. Esser initially reviewed Ortlieb's medical records and consulted with Ortlieb's primary care physician and gastroenterologist. Based on her record review and consultations, Dr. Esser determined TPN services were investigational and were not supported by peer literature. On December 7, 1999, Dr. Esser wrote Ortlieb explaining United HealthCare was denying coverage based on the Plan's exclusion for experimental, investigational, and unproven services. 16 Within weeks of denying coverage, United HealthCare received a request for reconsideration accompanied by a detailed letter from Dr. Rea. Although Dr. Rea's letter declared Ortlieb's receipt of TPN services was a medical necessity and also stated TPN therapy had been used at the EHC clinic for over twenty-five years with more than five thousand patients and... no significant long-term effects have been noted, Dr. Rea's letter cited no peer-reviewed medical literature indicating TPN services are a safe and effective treatment for Ortlieb's medical conditions. 17 Because the reconsideration request included a first-time coverage request for intravenous mineral and antibiotic therapy, United HealthCare requested additional medical records. In March 2000, Ortlieb formally appealed the initial denial of coverage, and in April 2000, United HealthCare hired Dr. Beer, an outside physician consultant, to review Ortlieb's medical records and to make an independent benefit determination. Dr. Beer determined (1) the records reflected insufficient objective data for cause of malnutrition; and (2) the requested TPN services were investigational and unsupported by sufficient medical evidence in Ortlieb's case or in the literature indicating any clinical improvement. Based on these findings, Dr. Beer recommended denial of coverage. 18 Near the same time, Dr. Esser reviewed the coverage request for Ortlieb's supplemental intravenous mineral and antibiotic therapy services. Relying on the documentation provided, Dr. Esser determined the requested TPN therapy services were investigational and not a covered benefit. On May 23, 2000, Dr. Esser wrote two denial-of-coverage letters. One letter notified Ortlieb that United HealthCare was denying the coverage request for supplemental, intravenous mineral and antibiotic therapy services. Dr. Esser's letter explained: 19 There is no documentation of positive cultures of an infection that would require intravenous antibiotics. It is also documented in your records that you are allergic to all antibiotics, yet intravenous antibiotics were given. Without supporting documentation of an infection, use of antibiotics is considered investigational and not a covered benefit. 20 Dr. Esser's second letter denied Ortlieb's request to reconsider the initial denial of coverage for TPN services. Although the letter did not refer to Dr. Beer by name, Dr. Esser informed Ortlieb her file has been carefully reviewed by a physician consultant who was not involved in the initial decision, which had resulted in an independent determination that the previous decision should be upheld. Dr. Esser explained: 21 There is also insufficient evidence in your medical records and peer-reviewed medical literature that TPN (and especially vitamin/mineral/anti-oxidant supplementation) results in clinical improvement. Therefore, the use of TPN is considered investigational and the TPN, supplies, and skilled nursing visits are not covered under your benefit plan. 22 Ortlieb then pursued an intermediate appeal to the CAC. United HealthCare representatives, including physician member Dr. Mergens, reviewed Ortlieb's file and upheld the decision to deny coverage. United HealthCare notified Ortlieb of the CAC's decision in January 2001, citing, as the basis for denial, the experimental, investigational, or unproven service exclusion. 23 Ortlieb filed her final administrative appeal with the NASC, which was independently processed by Edina, an external review company. Edina retained Dr. Flick, an independent, board certified, gastroenterology consultant. In August 2002, Dr. Flick reviewed Ortlieb's medical records and found no peer-reviewed literature supporting TPN therapy treatment for any of Ortlieb's proven diagnoses. Dr. Flick concluded TPN treatment to be unproven for [Ortlieb's] clinical condition(s). Edina notified Ortlieb that, based upon an independent external review, TPN was not a covered service because TPN treatment is unproven for Ms. Ortlieb's clinical condition, and unproven services are excluded under the Plan. 24 This recitation of the record illustrates that Ortlieb's coverage request for TPN therapy was reviewed at least four times by four physicians, two of whom were external, independent physician consultants. Each of the physicians reviewing Ortlieb's medical file consistently determined TPN therapy was an unproven therapy for Ortlieb's medical conditions. At least three of the four reviewing physicians concluded there was insufficient peer-reviewed literature supporting TPN therapy for Ortlieb's medical conditions. All five denial-of-coverage notices explained Ortlieb's coverage request for TPN therapy and related services was being denied based on the Plan's exclusion for experimental, investigational, or unproven services. All but the final denial notice, which was issued by Edina, specifically cited to and quoted the Plan's exclusion provision. Moreover, Dr. Esser's May 2000 letter informed Ortlieb there was insufficient ... peer-reviewed medical literature that TPN ... results in clinical improvement. Despite receiving these notices that clearly and consistently identified the bases for coverage denial-unproven service and insufficient peer-reviewed medical literature-neither Ortlieb nor her treating physician provided United HealthCare with clinical evidence or peer-reviewed literature establishing TPN therapy was a proven therapy for Ortlieb's medical conditions. For these reasons, we conclude Ortlieb's arguments are without merit, and United HealthCare's denial of coverage is reasonable. 3