> So any plan-approved doctor can try anything at any expense?
No. A review process of some kind is reasonable. One utilizing hand-picked doctors who haven't practiced in 30 years (see the section with Dr. Nady Cates), and not ever in the relevant speciality, is less reasonable.
For a case this complex, the denials shouldn't take minutes. They shouldn't be able to hand-pick a doc from the supposedly independent review organization. And they shouldn't be able to suppress reports from their own experts that say it's medically appropriate.
> Dr. Nitin Kumar, a gastroenterologist in Illinois, concluded that McNaughton’s established treatment plan was not only medically necessary and appropriate but that lowering his doses “can result in a lack of effective therapy of Ulcerative Colitis, with complications of uncontrolled disease (including dysplasia leading to colorectal cancer), flare, hospitalization, need for surgery, and toxic megacolon.”
> Unlike other doctors who produced reports for United, Kumar discussed the harm that McNaughton might suffer if United required him to change his treatment. “His disease is significantly severe, with diagnosis at a young age,” Kumar wrote. “He has failed every biologic medication class recommended by guidelines. Therefore, guidelines can no longer be applied in this case.” He cited six studies of patients using two biologic drugs together and wrote that they revealed no significant safety issues and found the therapy to be “broadly successful.”
> Gesk discovered it by accident when he was listening to a recorded telephone call produced by United in which Kavanaugh mentioned a report number Gesk had not heard before. He then called MRIoA, which confirmed the report existed and eventually provided it to him.