Panel reverses
HMSA decision

The state panel says the insurer
should have paid for a PET scan

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By Helen Altonn
haltonn@starbulletin.com

The Hawaii Medical Service Association "did not act reasonably" in denying coverage for a high-tech procedure for a patient, a review panel appointed by state Insurance Commissioner Wayne Metcalf has found.

Dr. Arleen Jouxson-Meyers, president of patient advocacy group Hawaii Coalition for Health, appealed the HMSA's denial on behalf of her husband, Edwin Jouxson. He was covered by HMSA's Preferred Provider Plan, but the medical service provider refused to pay for a Positron Emission Tomography scan at the Queen's Medical Center.

The review panel reversed HMSA's decision in a 2-1 vote last month, saying the test was medically necessary and a covered benefit.

Dr. Ronald Wong, colon and rectal surgeon, recommended the PET scan to determine if a large polyp in Jouxson's colon was cancerous. He said the alternative was high-risk surgery involving up to a week of hospitalization and five to six weeks for recovery.

The couple paid $3,500 for the test, done Sept. 5, 2000, on an outpatient basis. It showed the polyp was negative.

HMSA Senior Vice President Cliff Cisco said then, and again yesterday, that evidence does not support use of the PET scan for such a procedure. He said HMSA's physician reviewers judged the case on the basis of information from local and mainland experts.

Jouxson's attorneys, Raphael G. del Castillo and Richard S. Miller, said HMSA ignored an independent review it sought from Dr. Carol Marcus, a nationally recognized California nuclear medicine physician. She said the Jouxson case was "a perfect example of how a benign, noninvasive diagnostic test" can avoid a major surgical procedure, save a patient from surgical risks and pain, and decrease unnecessary surgical costs.

Del Castillo said HMSA informed doctors before receiving Marcus' opinion that it would accept that opinion if it differed from the HMSA medical director's opinion.

Instead, HMSA put a second question to Marcus, he said. "She was pretty indignant. She wrote back and said, 'My opinion doesn't change based on your rephrasing of the question.'"

HMSA then sought another opinion from a gastroenterologist with no qualifications to decide on use of a PET scan, del Castillo said. He said Dr. Marc Coel, director of Queen's nuclear research department, testified that the PET scan is useful in diagnosing primary colorectal cancer.

"It's true that we sought opinions from different people, both locally and on the mainland," Cisco said. "Medical science on use of the PET scan, based on current peer journals, is mixed. We got responses from both sides."

Cisco said HMSA's physicians based their judgment on information that justified their position. "At this point we don't believe there is any reason to change our internal processes for the handling of reviews and appeals."

Cisco said HMSA was upheld in five of six cases appealed to the insurance commissioner since the patients' rights law went into effect in 1998. "This is the only case where it was reversed."

Although HMSA maintains there is no evidence to support the use of the PET scan to diagnose colorectal cancer, it will pay for PET scans to watch such cancer once it is diagnosed, del Castillo said. He said Medicare, usually the last to approve anything, approved the PET scan to diagnose primary colorectal cancer a few months after HMSA denied Jouxson's claim.

Miller said the review panel's decision goes beyond the Jouxson case and "sets up a way to follow the law on 'medically necessary.'

"I think they've (HMSA) got to take a different view on how to make decisions like this. They cannot be overbearing and take a narrow view that ignores literature out there, and they cannot ignore experts."

Del Castillo and Miller submitted their fees to the insurance commissioner this week, seeking payment from HMSA.