Court Opinion

ID: 9574737
Source: CourtListenerOpinion
Date Created: 2023-08-21 21:07:37.48311+00
Date Added: 2024-06-11T12:44:53.763141
License: Public Domain

BENTON, J.,
dissenting.
Dr. William C. Stevenson concedes he altered the date of the stress test. The sole issue on appeal is whether the evidence is sufficient to prove beyond a reasonable doubt that the alteration of the date of the stress test operated “to the prejudice of [Trigon Blue Cross/Blue Shield’s] right.” I believe the evidence is insufficient because the Commonwealth did not meet its “burden ... to prove every essential element of the offense beyond a reasonable doubt.” Moore v. Commonwealth, 254 Va. 184, 186, 491 S.E.2d 739, 740 (1997). Viewed in the light most favorable to the Commonwealth, the evidence failed to prove that Stevenson’s alteration of the date of the stress test, under the facts of this case, could have prejudiced Trigon.
The evidence proved that in the mid-1970s Leonard Kraditor underwent a coronary bypass operation because of coronary artery disease. Kraditor had his first liver transplant operation in 1989 and survived the surgery without cardiac complications. In December 1995, Stevenson was treating’ Kraditor and determined that Kraditor needed another liver transplant. Stevenson informed Trigon of the following:
We have evaluated [Kraditor’s] cardiac, renal and pulmonary function and repeated tests to rule out other causes. We have reviewed his case in our candidate selection meeting and feel he is a good candidate for re-transplantation. We are now seeking financial approval from you to proceed with ... Kraditor’s treatment.
Trigon tentatively denied pre-authorization for Kraditor’s transplant surgery and requested additional information concerning Kraditor’s cardiac condition.
*463Stevenson altered the date of Kraditor’s earlier stress test. However, when Stevenson altered the date, Kraditor had already undergone the liver transplant surgery and had survived the surgery without cardiovascular complications. Although Trigon relied upon the stress test in granting preauthorization for the transplant surgery after the surgery had been performed, the evidence failed to prove that the preauthorization could have affected either Trigon’s final benefits determination or Trigon’s obligations under its insurance contract. Trigon’s senior officials testified that Trigon was contractually obligated to pay for the operation once Kraditor survived the surgery without cardiac complications, notwithstanding either the alteration of the date of the stress test or Trigon’s pre-authorization for the treatment already given.
The evidence proved, at most, that pre-authorization is a “service” that gives health care providers a “preliminary indication” whether the treatment will be covered by Trigon. Indeed, Dr. Richardson Grinnan, Trigon’s Senior Vice President and Chief Medical Officer, testified as follows:
We provide the pre-authorization process as a service to physicians and subscribers to prevent after-the-fact medical necessity denials. In this particular incidence, we didn’t receive the information, but given the fact — and we would have required that he have that information submitted to us in advance to give them some preliminary indication of whether or not we would have covered the surgery, but not receiving the information in advance, but with him surviving the operation, it would not have had an adverse determination on whether or not we would have paid that bill.
Marietta Boyce, a registered nurse employed by Trigon, testified that Kraditor’s insurance policy did not require Kraditor or his physicians to seek pre-authorization from Trigon as a condition of coverage.
The Commonwealth failed to prove that, after Kraditor survived the surgery without cardiac complications, the stress test itself could have had any bearing on Trigon’s final benefits determination for the transplant surgery. The evidence *464undisputedly proved that a final benefits determination had to be made by Trigon when the claim was submitted and before Trigon paid for the surgery. Dr. Grinnan testified that because Kraditor “underwent successful surgical intervention without cardiac complications ... [,] the test result [was] a non-contributory factor relative to final benefits determination.” Consistent with that testimony, Dr. Lawrence Colley, who supervises Boyce in the department responsible for Trigon’s coverage policy and reimbursement rates, testified as follows:
Q. ... You indicated that had you known that Mr. Kraditor had undergone the liver transplant operation and that he did not have any cardiac event either during or after the operation and that, in fact, he died I think on February 2nd, I believe, because his body rejected the transplanted liver, Trigon would have approved coverage for that transplant operation, wouldn’t it?
A. I stated that, yes.
Although the majority states that Boyce, the registered nurse who is supervised by Dr. Colley, explained a nexus between Trigon’s pre-authorization and its payment of benefits, the excerpt from Boyce’s testimony in the majority opinion clearly proves that her testimony was limited to explaining that she had pre-authorized only “[f]or the transplant itself’ and not the payment of the claim. Any doubt about the limited nature of her testimony is dispelled by her response to the following questions:
Q. All right. And ... do you know Dr. Colley?
A. That’s my boss.
Q. Okay. And do you know Dr. Grinnan at Trigon?
A. That’s my boss’s boss, yes.
Q. Okay. Dr. Grinnan is above Dr. Colley and Dr. Colley is above you.
A. Correct.
Q. You know now, don’t you, that Dr. Grinnan and Dr. Colley will say that if Trigon knew that Mr. Kraditor had successfully undergone the liver transplant operation on *465January 29th, I think, without any incidence of a cardiac arrest or cardiac event, that it wouldn’t have made any difference to them whether or not Trigon had a cardiac stress test? Don’t you know that Dr. Colley and Dr. Grinnan have taken that position?
A. Yes.
In addition, the majority’s assertion that Trigon would not have made a final benefits determination because it had provided a pre-authorization service is based upon a misunderstanding of Dr. Grinnan’s testimony. The full context of Dr. Grinnan’s testimony in that regard is as follows:
Q. Does Trigon Blue Cross/Blue Shield have different procedures with respect to the pre-approval and post-approval of medical care coverage?
A. Not everything is pre-approved. Pre-approval is the process that we make available as a service to doctors to avoid problems. We review cases after the fact if they haven’t been pre-approved and we make determinations based on information that’s available.
That testimony does not imply that pre-authorized procedures are not reviewed for final benefits determinations when claims are submitted. Dr. Grinnan merely stated that in those cases where no request for pre-approval has been made, a benefits determination will be made when the claim is submitted.
Once the surgery had been performed on Kraditor, the pending application for pre-authorization was rendered moot. Dr. Grinnan testified that the stress test, required by Trigon to measure pre-operative risk, was then a “non-contributory factor relative to final benefits determination.” At that point, the date-altered stress test had no potential to prejudice Trigon’s rights because “it does not fix, nor could it operate, any pecuniary liability upon [Trigon].” Terry v. Commonwealth, 87 Va. 672, 674, 13 S.E. 104, 104 (1891).
Considered in the light most favorable to the Commonwealth, the evidence proved that Kraditor survived the surgery without cardiac complications and later died because of liver and renal failures, causes unrelated to cardiac complica*466tions. The evidence also proved that Stevenson’s alteration of the date of the stress test, the act the Commonwealth sought to prove to be a forgery, was “a non-contributing factor relative to [Trigon’s] final benefits determination.” Thus, the evidence failed to prove beyond a reasonable doubt that Stevenson forged the stress test to the potential prejudice of Trigon. Accordingly, I would reverse the conviction and dismiss the indictment.