Physicians, Insurers Clash Over Medical Necessity in CA

Joe Cantlupe, for HealthLeaders Media , September 27, 2012

Mendoza's physician advised minimally invasive, robotic-assisted surgery that Health Net was willing to cover, a $14,000 cost, Delgadillo says. Mendoza received a second opinion from Gary Lieskovsky, MD, former head of the University of Southern California Norris Cancer Hospital, who recommended that Delgadillo needed a radical procedure, not robotic surgery, to save his life.

Mendoza worked with Dr. Lieskovsky to obtain a pre-authorization from Health Net for the procedure, which would have cost twice as much as the robotic surgery. Health Net denied the claim, stating the procedure was not medically necessary, according to the lawsuit.

Mendoza paid for the $30,000 surgery out-of-pocket because he believed it gave him the best chance for survival, according to the court papers. To pay his medical bills, he said he cashed in his wife's life insurance policy and used money he had set aside to pay his income taxes as a self-employed court interpreter.  Eventually, Lieskovsky performed the surgery, and Mendoza now has a good prognosis, Delgadillo said.

"All this was done very quickly, from when the insurance was denied to when the surgery had taken place," Delgadillo says.

"My life was at stake with months to live. I had no time to fight the bureaucratic red tape with Health Net," Mendoza said in statement. "It's a shame and inhumane that it wouldn't even approve a procedure that could have saved my life. A procedure that cost a fraction of the premiums I paid."

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