Class Action Lawsuit Against Health Insurance Company Alleges Improper Coverage Denial for Necessary Medical Treatment

Robert S. Gianelli, Los Angeles insurance attorney

Gianelli & Morris

Gianelli & Morris

Insurance firm Gianelli & Morris filed a lawsuit against Anthem, Inc. for improperly denying cover for the Coflex device for the treatment of lumbar spinal stenosis.

Despite the fact that surgery with Coflex has been FDA cleared for years and recommended by top spine surgeons across the country, Anthem categorically denies that it qualifies as an “investigation”.

– Robert S. Gianelli

LOS ANGELES, CALIFORNIA, UNITED STATES, Aug. 3, 2021 / – On July 29, 2021, California insurance firm Gianelli & Morris filed a class action lawsuit in the United States District Court for the Central District of California. The case is Brenda Honeycutt v Anthem, Inc. (Case No .: 2: 21-cv-6124). The lawsuit demands, among other things, benefits from the disputed insurance policy, the clarification of rights and future benefits, a class-wide injunction and the skimming of profits from the allegedly wrongly refused insurance benefits.

The lawsuit alleges that Anthem, Inc. and its subsidiaries wrongly denied claims to have surgery with Coflex, an interlaminar stabilization device used to treat lumbar spinal stenosis.

According to court documents, lumbar spinal stenosis is a debilitating and degenerative disease that affects 1.6 million patients annually. The disease causes significant leg and back pain, numbness, and weakness. Traditional surgical treatment options include decompression by removing bone and soft tissue, sometimes accompanied by fusion of vertebrae to stabilize the spine.

Coflex is an “interlaminar stabilization device” that is inserted through a minimal incision to keep the decompressed area of ​​the spine open and on the table. When combined with Coflex, decompression procedures are said to be more durable and sustainable, as patients are less likely to need another operation or other future interventions. Court documents claim that Coflex has better results than decompression, causing less trauma and faster recovery than fusion, and is not inferior to decompression with fusion.

Lawsuit says applications to use Coflex are categorically denied

Documents submitted to the court state that Anthem categorically rejects all applications for Coflex as an object of investigation and not medically necessary. In particular, the complaint by the plaintiffs cites from Anthem’s Medical Policy for Implanted Devices for Spinal Stenosis, SURG.00092, an internal company guideline that considers the use of Coflex to be “subject to testing and not medically necessary”.
According to the complaint, when Ms. Honeycutt’s application for Coflex was denied, Anthem relied on its coverage policy to say that Coflex was not required to keep the decompressed room open and claimed that not enough studies had been done to allow it show that Coflex is safe and effective. The complaint alleges that Anthem is relying on this policy to deny any claims to Coflex regardless of the individual patient’s health, needs, or qualifications for the device.

The lawsuit cites from Plaintiff’s Anthem Plan, which defines an investigative process as a process that does not have final regulatory approval, does not contain credible scientific evidence published in peer-reviewed medical literature, and which is not proven improving the patient’s net health outcome has not been shown to be as beneficial as an established alternative and has not shown improvement outside of the exam setting.

In response to Anthem’s allegations of Coflex as a candidate, the lawsuit alleges that Coflex is a Class III medical device that was FDA approved in 2012 under the agency’s pre-market approval process, which includes human clinical trials and numerous studies and Requires research into the safety and effectiveness of the device. The complaint also alleges that Coflex has been the subject of additional peer-reviewed clinical studies, has gained wide acceptance by spine surgeons across the country, and has received positive reporting recommendations from the International Society for the Advancement of Spine Surgery, the North American Spine Society . the American Pain Society and the National Institute for Health and Care Excellence.
Lead plaintiff’s attorney Rob Gianelli stated, “Anthem has refused to provide necessary medical treatment to its members with severe back problems who require Coflex surgery. Despite the fact that surgery with Coflex has been FDA approved for years, recommended by leading spine surgeons across the country, and relieves patients of chronic pain and disability, Anthem categorically denies that it is “in need of investigation.” This class action lawsuit aims to eliminate this injustice. “

This class action lawsuit is being filed on behalf of anyone who is on ERISA health plans, self-funded, or fully insured, managed by Anthem and whose claims to Coflex have been denied because treatment is investigated and medically unnecessary. The lawsuit clarifies that Coflex is insured and not medical examination or medical necessity. The plaintiff also requests a reassessment of all disputed claims without the allegedly incorrect grounds for rejection and a clarification of the members’ claims to future benefits. The plaintiff is also seeking an injunction stating that the disputed denials were false and inappropriate, and urges Anthem to withdraw the allegedly incorrect formulation of the medical guidelines and notify all members of the group of the withdrawal. The lawsuit requires a surcharge in the form of accounting for and siphoning off any profits earned and withheld from improper denial of claims, along with payment of attorney’s fees and other reasonable and remedial measures that the court deems fair and reasonable.

Carter P. Spohn
Gianelli & Morris, a law firm
+1 213-489-1600
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August 03, 2021 at 4:09 pm GMT

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