In August 2021, Kantor & Kantor filed a complaint against one of California’s largest insurer’s in the Superior Court for the State of California, County of Los Angeles on behalf of a client who was denied coverage for an explant surgery.
After a routine mammogram in 2013, and a subsequent biopsy, Kantor & Kantor’s client, a 60-year-old woman, was advised her risk of developing breast cancer was higher than the general population based on the presence of the papillomatous tissue. Upon being advised that she would be a good candidate for one-stage breast reconstruction, the client underwent a bilateral mastectomy with bilateral breast reconstruction in February of 2014.
In 2019 the client contacted her surgeon reporting chronic pain over the chest wall and into her back, despite physical therapy. The client reported that the pain had gotten consistently worse over a few years and was limiting her activity and causing daily pain.
Her surgeon recommended that the implants be removed and submitted a pre-authorization request to her insurer for bilateral removal of intact mammary implants and bilateral periprosthetic capsulectomy of the breast. This request was denied by the insurer. The surgeon submitted a second request.
The insurer denied both requests for pre-authorization, both times stating the procedure was not medically necessary. The surgeon then participated in a peer-to-peer review with a doctor from the insurance company, who upheld the denial noting that the client did not qualify for surgery as she “looked okay” and stating her other medical issues were “meaningless” and did not qualify as medically necessary.
In February of 2020 the client underwent a bilateral implant removal – also referred to as explant surgery. During the procedure, her surgeon discovered that the left implant was ruptured, with silicone visible outside the implant.
As a result of the insurer’s denial, the client incurred the cost of the surgery. She filed a grievance with the insurer soon thereafter. The insurer denied the client’s request for breast reconstruction surgery again on the grounds that the service was not medically necessary.
As a last resort, the client submitted an Independent Medical Review/ Complaint Form (“IMR”) to the CA Department of Managed Health Care. The decision from the IMR not only upheld the insurer’s denial but it was full of factual errors. Kantor & Kantor filed a Final Appeal & Request to Reprocess Plaintiff’s Claims to the insurer. The insurer upheld their denial yet again, causing Kantor & Kantor to file a complaint in State Court.
Fast forward to August 2022. The case has been settled and dismissed and Kantor & Kantor’s client is pleased with the result and happy to have this behind her.
The Plaintiff was represented by Kantor & Kantor LLP Partner, Cari M. Schwartz.
If you or someone you know has been denied healthcare benefits or access to treatment, please call Kantor & Kantor for a free consultation or use our online contact form. We understand, and we can help.