Managed Care Litigation Update Volume 211: October 31, 2022

• Publication year: 2022

NEWSWORTHY

District court grants, in part, motions to dismiss filed by ERISA plans where "out of network, out of service area, health care provider for complex surgical services" alleged underpayment, holding that 29 USC 1133 does not confer a private right of action and that the administrators were not fiduciaries. Advanced Orthopedics and Sports Medicine Institute, et al. v. Anthem Blue Cross Life and Health Insurance Company, et al., USDC D. NJ, No. 20-cv-13243-FLW, 2022 WL 13477952, (Doc. 62, filed Oct. 21, 2022). Previously reported at MCLU Vol. 161.

District court affirms denial by ERISA plan of claims for Azitrhomycin where plaintiff failed to file an internal appeal and failed to demonstrate that doing so would be futile. Fischer v. Rocky Mountain Hosp. and Medical Service, Inc., USDC D. CO, No. 21-cv-1489-CMA-MEH, 2022 WL 13682928, (filed Oct. 21, 2022). Previously reported at MCLU Vol. 178.

Department of Justice intervenes in FCA action alleging Cigna included invalid patient diagnosis information to inflate Medicare Advantage payments through its risk adjustment data, asserting that Cigna relied on vendors to conduct in-home assessments who did not order the testing, imaging, or other diagnostic steps necessary to reliably diagnose the conditions listed. United States v. Cigna Corporation, et al., USDC MD TN, No. 3:21-cv-748, (Doc. 178, filed Oct. 14, 2022).

RECENTLY FILED ACTIONS

Dr. Arash Emami v. Aetna Life Insurance Company, et al., U.S.D.C. D. NJ, Doc. No. 2:22-cv-6115-KSH-LDW, (filed Oct. 17, 2022). OON physician and alleged assignee seeks ERISA benefits associated with back surgery to treat "severe left-sided paracentral L4-L5 disk herniation with left lower extremity radiculopathy." Billed charges were $125,980. The claim was denied as not medically necessary on the grounds there was no documented stenosis.

Trevor T., et al. v. California Physicians' Service, et al., U.S.D.C. D. UT, Doc. No. 1:22-cv-140-JNP, (filed Oct. 18, 2022). Member seeks ERISA benefits associated with residential treatment at Elevations Seven Stars. The claim was denied as not medically necessary pursuant to the 2019-2020 Magellan Care Guidelines as adopted by Blue Shield's MHSA - Residential Behavioral Health, Child or Adolescent.

Norman Maurice Rowe, M.D., M.H.A., LLC, et al. v. Unitedhealthcare Service, LLC, U.S.D.C. E.D. NY, Doc. No. 2:22-cv-6297-GRB-AYS, (filed Oct. 18, 2022). Removed action in which OON physician and alleged assignee seeks benefits and...