Editor’s Note: On Wednesday, Feb. 14, the judge in the case referenced in the original CNN story delayed the trial for at least six months due to the media coverage that he described as “slanted” and “one-sided.” Reporters from outlets such as Kaiser Health News and FierceHealthcare have posted updates on their original stories to include this new information.
Much attention has been paid to a recent CNN story that called into question how coverage decisions are made by Aetna medical directors. The story was pushed by attorneys for an individual suing Aetna; in fact, it was conveniently published days before the trial was scheduled to begin. In it, based on an excerpt from a deposition, former Aetna medical director Dr. Jay Ken Iinuma appears to imply that he never relied on medical records when making coverage decisions.
We want to be 100 percent clear with our members, customers, partners and the public: Dr. Iinuma’s deposition was taken out of context to create media and courtroom leverage, and is a gross misrepresentation of how the process actually works. Medical records were in fact an integral part of the clinical review process during Dr. Iinuma’s tenure at Aetna, consistent with his training.
Shortly after the story was published, Dr. Iinuma made that clear in a sworn statement:
“In addition to reviewing the relevant portions of submitted medical records, it was also generally my practice to review Aetna nurses’ summaries, notes, and the applicable Aetna Clinical Policy Bulletins. After reviewing the relevant, submitted portions of the medical record, the nurse’s notes, and the Clinical Policy Bulletin(s), I would apply my medical training, experience, and judgment to reach an appropriate coverage determination.”
Aetna medical directors review all necessary available medical information for cases that they are asked to evaluate. That is how they are trained, as physicians and as Aetna employees. In fact, adherence to those guidelines, which are based on health outcomes and not financial considerations, is an integral part of their yearly review process. As Dr. Iinuma stated in his deposition, his evaluation “was to ensure care was being provided in a safe and effective manner.”
Another important point of clarification from the CNN story, and resulting coverage: Aetna has paid for each and every treatment the individual suing Aetna has received since he first submitted a claim under his health plan in 2014. He remains an Aetna member today, and we continue to pay for his treatments. The only interruption in his treatment was the result of the individual defying his doctor’s orders and refusing to provide necessary bloodwork. That is made clear in the CNN story:
Aetna initially paid for his treatments after each infusion, which can cost up to $20,000. But when Washington’s clinic asked Aetna to pre-authorize a November 2014 infusion, Aetna says it was obligated to review his medical record. That’s when it saw his last blood work had been done three years earlier for Kaiser.
Despite being told by his own doctor’s office that he needed to come in for new blood work, Washington failed to do so for several months until he got so sick he ended up in the hospital with a collapsed lung.
Our policies always have our members’ best interests in mind. When those policies are called into question, we will defend them.