Radiologist rails against insurer’s refusal to cover key interventional service
A radiologist is railing against health insurer Cigna’s refusal to cover a key interventional service.
Michael Ginsburg, MD, shared his frustrations Dec. 18 on social media after the Bloomfield, Connecticut-based payer declined to reimburse for prostate artery embolization. The IR specialist, who practices in South Bend, Ind., was working to treat an older man’s enlarged prostate but ran into a roadblock when seeking preapproval.
EviCore, a different division of Cigna, informed Ginsburg in late November that the service was not medically necessary.
“Cigna has to update their policy as [prostate artery embolization] is included in guidelines of multiple organizations including [the] American Urological Association, Society of Interventional Radiology, and [the] European Association of Urology,” Ginsburg shared on Twitter Wednesday. “Alternatively, this is a class-action lawsuit waiting to happen against both Evicore and Cigna for inflicting medical damage on patients.”
Ginsburg also shared an October investigation from ProPublica, which explored EviCore’s business model. The company markets itself to insurers promising a 3-to-1 return on investment. So, for every $1 a payer spends on EviCore, it can expect to pay out $3 less on medical care and other costs, ProPublica noted. Ginsburg is disgusted by the hiring of an intermediary like “EvilCore.” This passes on the “dirty work to deny coverage so they can split the profits,” “preventing patients from accessing crucial care leading to devastating consequences.”
Asked to comment on the social media post, Cigna shared a statement from EviCore, which is part of Evernorth Health Services, the health insurer’s medical practice division, similar to UnitedHealth’s Optum.
“We always welcome input from both individual clinicians and medical societies regarding our evidence-based guidelines,” the representative told Radiology Business Thursday. “We have heard the feedback on our prostate artery embolization policies and are actively reviewing the evidence to ensure our guidelines reflect the highest quality evidence and remain up to date.”
In an interview, Ginsburg expressed frustration about the insurers’ so-called peer-to-peer processes to discuss such decisions. The doctor he spoke with over the phone was not an interventional radiologist nor a urologist and did not understand the clinical evidence supporting PAE in this case. Ginsburg is now contemplating whether to submit a third appeal, and he also has spoken with an IR colleague at his Indiana health system who experienced a PAE denial.
“Cigna's policy states that it's an experimental procedure, and that’s just not true,” Ginsburg told Radiology Business. If [the peer reviewer] were a urologist or interventional radiologist treating this patient population, they would know the American Urological Association guidelines were updated a year and a half ago. I'm not talking about a couple months ago. Almost two years ago. So, this is substandard care.”
He questioned the purpose of such peer-to-peer discussions if there is no real possibility of an insurance representative changing their mind. Ginsburg believes continued refusals will force patients to undertake more invasive approaches, and to drive to farther away to larger hospital locations rather than nearby community-based outpatient alternatives.
Ginsburg guesses that most radiologists eventually give up in these scenarios, but he prides himself as a patient advocate and plans to keep fighting through a third appeal and beyond.
“If you as an insurance company don't cover the standard of care, then you fail in this contractual agreement with your patients. That's how I view it,” he said. “I'm upset that I have to spend time to argue for something that is within the clinical guidelines. This is not right.”
Marty Stempniak has covered healthcare since 2012, with his byline appearing in the American Hospital Association's member magazine, Modern Healthcare and McKnight's. Prior to that, he wrote about village government and local business for his hometown newspaper in Oak Park, Illinois. He won a Peter Lisagor and Gold EXCEL awards in 2017 for his coverage of the opioid epidemic.