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Appealing Decisions

Appealing Decisions

Complete the questions below based on the problem identified. Your written response should be no less than two to three pages in length.

Problem: Mr. H. was a diabetic and had severe ulcers on his feet. He was a member of an HMO, and his primary care physician had prescribed a treatment regimen that was proving ineffective. In response, the primary care physician offered Mr. H. an amputation below the knee that was his only option. Mr. H. went out of plan to a local wound care center that specialized in diabetic wound treatment where he was advised that vein by-pass surgery would likely take care of his problem. The HMO denied such surgery because Mr. H. referred himself to the specialist without permission. The HMO advised Mr. H.’s family that its utilization review department was reviewing the case, but that it would take at least a month to review. Subsequently, the HMO agreed to approve such surgery, but only if done by Mr. H.’s current medical group, which did not have any physician who had ever performed vein by-pass surgery. Mr. H.’s family asked for him to be transferred to a primary care physician at the medical group that staffs the wound care center. The HMO responded that although they sometimes approve such requests, they would not do so in Mr. H.’s case and that they had already granted enough of his requests. They gave as their reason a provision in the plan documents that prevent referrals outside the plan’s network when the network’s physicians have the capability to perform the required procedure.

This problem is adapted from a real case history developed by the Center for Health Care Rights in California.
• What procedural remedies does the patient likely have under private insurance and under Medicare or Medicaid?
• Are they adequate?

Be sure to include the following based on the criteria below:

Student examines legal issues related to healthcare rationing and medical necessity.

Student identifies remedies the patient would have under private insurance and if they are adequate.

Student identifies remedies the patient would have under Medicare and if they are adequate.

Student identifies remedies the patient would have under Medicaid and if they are adequate.


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