More on Nataline...

[Welcome CraigsList and California Medicine Man readers!]

If you're just tuning in, a teenager in California died recently, and there is quite a controversy surrounding the circumstances. The biggest problem so far is the lack of adequate information; while the parents are free to cast whatever accusations they want, the insurer (Cigna) is constrained by HIPAA (as well as the pending litigation).

The issue is whether Cigna "killed" Nataline.

Bloggers and commenters on both sides have weighed in, but with only one side's take on the matter, it's difficult to really understand what happened. In an effort to clarify some of the issues, I contacted Cigna. I introduced myself, explained what we were doing, and asked some questions to help get a better picture. Although I knew that I was most likely to get a "Thanks, but we can't comment on pending litigation," I figured it was worth the effort. And sure enough, my first response basically echoed that demurral. I was disappointed, but not surprised.

What did surprise me was a follow-up email sent a few hours later, which included an email that the President and CMO of Cigna had sent to employees. It explained a few facts that had not been available before. Rather than post the whole thing (it's pretty long), I'll excerpt the relevant pieces for comment. The full text is here. Here are the relevant passages:

"Transplants are an enormously complex and emotional societal issue, in particular because of the scarcity of organs and the experimental and unproven nature of some of the treatments involved. In all circumstances, a completely independent national organization controls the allocation of organs for transplant based on a number of important considerations independent of any decision involving insurance coverage.

What is often misunderstood is that most health benefit plans, whether public or private, do not cover unproven and experimental treatment related to transplants or other treatments...At CIGNA, we facilitate payment for more than 90% of all requested transplants and specifically more than 90% of the liver transplant requests made to us.“

In other words, it’s not the “greedy corporate culture” that others might have one believe, but a rigorous and medically-sound process designed to maximize the potential for a successful operation.

“In this case, rather than going through our standard method of appeal, we went directly to not one, but two, independent experts in the field who agreed that the procedure in question, given the patient’s particular circumstances, would not have been an effective or appropriate treatment.“

This tracks with what we already know from the physicians involved on Nataline’s end, and actually goes above and beyond the SOP. There was apparently no reluctance to authorize based on “bean counting” mentality.

“Based on the unique circumstances of this situation, and although it was outside the scope of the plan’s coverage and despite the lack of medical evidence regarding the effectiveness of such treatment, CIGNA decided to make an exception.“

One may argue under what rationale that exception was made (I’m personally sure that public scrutiny probably paid a part), the fact is that companies do make these kinds of exceptions when warranted. In fact, I can speak from personal experience in that regard.

The bottom line here is that, absent more facts than have thus far made it into the public discourse, folks decrying the “heinous attitude” of carriers exhibit much wind and fury, but precious little insight. All we really know for sure is that two parents are grieving, and our hearts and prayers are with them.