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An acquaintance recently had a really bad experience with prior authorization. His health has steadily deteriorated since a diagnosis in 2020. He went in for a biopsy, which went south. He was under anesthesia and was transferred to ICU. The insurance refused to pay for the $16k ICU stay because it wasn’t pre-reapproved. How was he supposed to get it pre-approved while unconscious and in a dire situation? The kicker? This guy is a doctor and knows how to navigate the "health" care system.

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My favorite story about this and health insurance nonsense: transcranial magnetic stimulation for treatment Resistant depression is an FDA approved treatment. It’s been approved since 2008. The FDA label says one failed medication trial is the definition of treatment resistance. The payers have used 4 failed medication trials and to fail psychotherapy trials in the current episode, because this was the average number present in the FDA approval trial in 2008. Keep in mind there have been 4000 study since that time. They’re having multiple other FDA approvals across multiple other indications and multiple other protocols on multiple devices using brain stimulation with this approach. It is the safest and most effective treatment that has ever existed for depression. I submitted an appeal after a prior authorization for the treatment denied care for someone who would only failed one medication trial, but did not wish to take three more medication’s that wouldn’t work for months to years before they could get access to this treatment. It went to external appeal in the state of New York, and a board of three independent medical reviewers found it to be medically necessary. A complaint was placed with the state Attorney General about the process of unnecessary medical review. External medical reviewers concurred with my medical opinion, and found that united healthcare had no right to deny this treatment on appeal. Traditionally, when this happens and you have an attorney, general complaint from the patient along with it, the health payer is forced to pay for it ever onward--they’re external medical review which is independent trumps their internal medical reviewers, and when the Attorney General has a complaint, then enforce it. So, here is what united healthcare did next: they started denying my right to even place an appeal in the first place. I actually had to go to the courthouse to appeal my right to have an appeal. They knew if I got the appeal, I would automatically win, because external medical review had already deemed it medically necessary. And yet they continue to denying my right to appeal, and just not paying.

There is no winning, because there is no accountability. There are no criminal penalties for “healthcare” executives who pursue policies that violate both the corporate practice of medicine and medical ethics. Until that is the case, they will continue doing it. There is no such thing as a real financial penalty for United healthcare, it’s simply increases the cost of doing business, which increases the amount of money they can make.

Expect the nonsense to continue, until we end it.

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You might remember California denied the insurance industry the right to deny coverage this way, the Natalie Sarkisyan story, you should remember it, you wrote about it and explained why and how. Anyway, since her death the middle aged death rate in California has gone down while in almost all the rest of the USA it has gone up. If California had followed the rest of the United States they would've had about 35,676 more age 25-64 deaths from 2008 through 2019 and if the rest of the USA had followed California they would had about 535,598 fewer middle aged deaths at the same time. Let me know if you would like to see some of my other work on dying in the United States.

Dr. James H. Gundlach,

aka pecanjim@bellsouth.net

A retired demographer who roasts his coffee beans in a campfire popcorn popper over a pecan wood fire.

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