A story from Joan Chang, Senior Staff Attorney, Health Unit
CLA SoCal Health Consumer Action Center (Health Unit) client Gerry (fictitious name), an eight-year-old health consumer, needed assistance when his insurance plans denied a medically recommended speech generating device (SGD).
Gerry was diagnosed with Soto Syndrome (a rare genetic disorder that causes speech problems), along with autism spectrum disorder causing speech delay. The SGD was recommended by a speech pathologist as Gerry is functionally nonverbal and does not produce any true words. He is covered under two plans, Medi-Cal/CalOptima and Blue Shield Platinum 90 PPO (a private, off-exchange plan paid for by Gerry’s aunt) and when both plans denied the device, Gerry’s parents contacted CLA SoCal for help.
The response
Health Unit attorney Joan Chang prepared a detailed Statement of Position in response to CalOptima’s arguments for denying the device. In the statement, she identified that CalOptima cited the wrong adult medical necessity standard for an 8-year old health consumer. Joan also researched and discovered CalOptima failed to apply their own policy criteria for “augmentation and alternative communication devices (AAC)”, for which she demonstrated Gerry met each of the criterion.
Joan argued CalOptima improperly relied upon clinical guidelines provided by MCG (a company that offers healthcare organizations clinical guidance) when there are existing Medi-Cal Clinical requirements for such devices. Lastly, she demonstrated that CalOptima’s “Peer Reviewer” added an additional requirement that is NOT listed on the Medi-Cal Provider Manual’s own criteria: requiring consumer to use the device on a trial basis for at least 4-weeks. CalOptima added an additional hurdle for Gerry to overcome that legally should not be there.
Furthermore
To highlight Blue Shield’s procedural failures, Joan prepared a 19-page California Department of Managed Health Care (DMHC) appeal. Blue Shield denied the device indicating the provider (the SGD manufacturer) was “out-of-state”, instead of treating it as a durable medical equipment request. Blue Shield also failed to send Gerry (his parents) a written copy of the original denial and grievance response letter. Additionally, Joan researched DMHC’s prior independent medical review (IMR) decisions and cited to the same published clinical studies the IMR physicians cited to demonstrate the medical benefits of such speech generating devices for autistic children.
Not only did the Medi-Cal administrative law judge decide in Gerry’s favor, but Blue Shield ultimately approved the device as well. Gerry’s father expressed his gratitude in a note and flowers by stating, “The SGD finally arrived yesterday. I could not have done this without your help, and I am very grateful. Thank you, Joan!”
