Whether coverage for an allogeneic stem-cell transplant ("allo-transplant") was properly denied by the insurer was at issue in Hawaii Medical Service Association v. Adams, No. 28899 (Haw. Ct. App. May 21, 2009) [here]. An allo-transplant, used to treat myeloma, involves the harvesting and transplanting of stem cells from a matched donor. A "myeloma" is a form of cancer which affects the bone marrow cells and involves several different bones at the same time.
Hawaii Medical Service Association ("HMSA") denied pre-authorization for an allo-transplant for the insured. Based on Blue Cross Blue Shield Association's Guidelines ("BCBSA Guidelines"),HMSA determined the request was "investigational." An internal appeal was filed pursuant to the policy's procedures. The appeal upheld the denial of pre-authorization for the allo-transplant because multiple myeloma was not listed in the policy as a condition for which an allo-transplant would be covered. Further, the BCBSA Guidelines only recommended use of allo-transplant to treat multiple myeloma in a clinical trial setting.
The insured appealed HMSA's denial to the Insurance Commissioner. The Notice of Proposed Order recommended HMSA be ordered to provide coverage for the allo-transplant. HMSA then approved the coverage, and the insured received the allo-transplant. The Commissioner's Discussion and Order agreed that an allo-transplant for multiple myeloma was not covered, but the exclusion was not specifically enumerated as an excluded benefit in Chapter 6.
The Circuit Court upheld the Commissioner's decision, but the Hawai`i Intermediate Court of Appeals reversed. The relevant statute, Haw. Rev. Stat. 432E-1.4 (a), stated coverage must be provided if recommended by the treating health care provider and determined by the health plan's medical director to be medically necessary, unless specifically excluded.
The policy language "specifically excluded" an allo-transplant as a treatment for multiple myeloma. Chapter 6 of HMSA's policy stated there was no coverage for transplant services other than those described in Chapter 4. Chapter 4 limited benefits for bone marrow transplants to allo-transplants "for the specified diseases or conditions described in this section." Chapter 4 then listed fourteen specific diseases or conditions for which an allo-transplant was covered, but did not include transplants for multiple myeloma.
Under the Commissioner's interpretation of the policy, HMSA would be required to list every conceivable medical condition for which coverage for allo-transplants would be excluded. This was neither practical nor reasonable.
Special thanks to my Damon Key colleague and fellow blogger, Mark Murakami (hawaiioceanlaw.com), for early notice of the Adams case.
