I’ve never been a fan of private health insurance. Why? Oh, a host of reasons. But one in particular is because a private health insurance company can still determine whether or not it wants to pay for a procedure it does not deem “medically necessary.” You see, I suffered from terrible pain to my left heel. Weeks went by until I finally decided to schedule an appointment with a podiatrist. Podiatrists know something about feet and ankles. After all, it’s their specialty. Harley Wishner is a urologist. Or at least if you visit his LinkedIn profile you will find that he consults in the area of Urology for Anthem/Blue Cross, a private health insurance company. Something tells me Dr. Wishner doesn’t know very much about podiatry. Otherwise, he might have arrived at a different conclusion about my particular situation.
Dr. Wishner denied me coverage for an MRI that was deemed “medically necessary” by my podiatrist. You see, my podiatrist wasn’t able to arrive at an accurate diagnosis of what was causing the tremendous pain in my heel making it impossible for me to walk without wearing a boot. X-rays were taken but proved to be inconclusive. It was my understanding that when my podiatrist recommended I get an MRI of my left heel that it was only if Anthem/Blue Cross would approve it. They did. I was not told that my insurance plan would not cover it.
I got my MRI and eventually received the appropriate care that I required. But medical reviewer, Harley Wishner, MD, knows nothing about this. This is because he works for a private health insurance company and it’s his job to review coverage requests and DENY those requests if they are not covered under your specified plan. Harley also doesn’t understand that the pain was in my HEEL and not in my foot.
Let’s review the offending paragraph in the notice I received from Anthem Blue/Cross:
Medical Reviewer, Harley Wishner, MD, has determined: We cannot approve your request for a low field MRI (a type of medical picture). Your request tells us that you have left foot pain. Medical studies we have seen do not show that low field MRI is as good as or better than other types of medical pictures for bone, muscle, or joint problems. For this reason we believe this testing is investigational. We based this decision on the health plan medical policy, Low Field and Conventional Magnetic Resonance Imaging (MRI) for Screening Diagnosing and Monitoring (RAD.00049H). Anthem Utilization Management Services, Inc. conducted this review.
Reading this paragraph not only angered me but I felt that the description of “left foot pain” did not even come close to accurately describing where the actual pain was and where it was located. Dr. Harley Wishner was not identifying the appropriate part of my body that suffered from pain and writes me a letter describing the body part that is incorrect. It was not my “left foot” and it was not my “left ankle.” It was my left heel.
I’m going to file a grievance against Anthem/Blue Cross and I’m going to get my podiatrist to fill out what is called a “physician certification experimental/investigational denials” form. The fact is, an MRI for my particular situation is not “experimental” and standard therapies were NOT effective in reducing the level of pain in my left heel.
I’ve drafted this blog post to not only shame Dr. Harley Wishner, MD, and his inaccurate diagnosis of my particular health situation but also to shame Anthem Blue Cross for doing what it does best (as do all private health insurance companies). That is to deny benefits and coverage to any person even if their doctor has deemed it medically necessary for a procedure in order to aid in the understanding and treatment of a particular ailment or disease.
And lest you forget. How do private health insurance companies fatten their profit? By denying coverage.
UPDATE: June 5, 2016
I received a letter from Anthem Blue Cross stating that my grievance was accepted and approved! Yeah! Instead of paying more than $3,000, I paid under $300 for my MRI. Thank you, Anthem for your consideration of my grievance and for agreeing with my reasoning.