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Cigna stands by decision on transplant

The insurer defends its initial denial of a liver procedure for a teen who died last week.

December 25, 2007|Lisa Girion | Times Staff Writer

A Friday funeral was set for the Northridge teenager who died last week after her insurer refused to pay for a liver transplant and then reconsidered. Meanwhile, the girl's health plan stood by its initial decision Monday.

Philadelphia-based Cigna HealthCare has a record of approving coverage for more than 90% of all transplants requested by its members, as well as more than 90% of the liver transplants, company President David Cordani said in a memo addressed to employees and distributed to members of the media.

Nataline Sarkisyan's request was evaluated on an expedited basis using "evidence-based guidelines published by independent physician and medical organizations, as well as expert scientific journals," Cordani said.

A leukemia patient, 17-year-old Nataline had been in intensive care at UCLA Medical Center for about three weeks after suffering complications following a successful bone marrow transplant Nov. 21, relatives said. She was covered under the policy of her mother, a real estate agent.

UCLA doctors put her on a list for a liver transplant Dec. 6 and a liver became available four days later, the family said. Her doctors told Cigna in a letter that patients in similar situations had a 65% chance of living six months if they received a liver transplant.

But the transplant was not done because Cigna deemed it experimental in Nataline's case and refused to pay for it.

The denial was publicized by the California Nurses Assn., the Armenian community and the Daily Kos blog on the Internet -- a campaign that resulted in telephone calls and e-mails to Cigna urging it to reconsider.

But last Thursday, Cigna made an exception and agreed to pay for Nataline's transplant because of the "unique circumstances of this situation," Cordani said in the memo.

The company authorized the transplant even though it still considered it experimental -- and therefore outside the scope of her coverage -- and "despite a lack of medical evidence regarding the effectiveness of such treatment," Cordani said.

But it was too late. The decision came the day Nataline died after her family decided, in light of her deteriorating condition, to take her off life support.

The family blamed Cigna's delay in obtaining coverage approval for her death and have said they would file a lawsuit.

Cigna's Cordani said in the memo that some unspecified accusations had "mischaracterized our decisions and intentions."

"Cigna did not reverse the clinical determination that the member's plan did not cover the transplant," Cordani said. "In fact, Cigna went above and beyond the plan and offered to provide payment in the event the procedure should be completed."

A Cigna spokesman said the company could not comment further because of patient confidentiality laws and the threat of a lawsuit.

Nataline's family referred questions about the memo to their lawyer, Mark Geragos. But her brother, Bedig Sarkisyan, said condolences the company issued after Nataline's death were too late.

"The day they denied my sister's transplant -- the day they denied her a chance -- that's the day I would have accepted their condolences," he said.

Geragos said the memo looked as if it had been written by lawyers and crisis communication experts.

He said that if Cigna "had spent one-tenth the amount of money they did on damage control on her organ transplant, she'd be alive today."

"The memo was just cloying and unforgivable and unforgiving, and shows that they are more concerned about them than their insured," Geragos said. "It just shows how out of touch they are."

The dispute highlights the conflicts between patients and insurers over the definition of experimental procedures and coverage limits.

The family's benefit plan, as with most health plans, does not cover experimental treatments.

Cigna's Cordani said the company went beyond its 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," the memo said.

The memo also was signed by Jeffrey Kang, a physician and chief medical officer for Cigna.

The memo did not identify the "independent experts in the field" whose advice it relied on in the appeal.

The initial denial was signed by a registered nurse, Geragos said.

"They said they sent it out to experts, which is ridiculous," he said. "Who would be the experts in that? They had the experts right there at UCLA."

The family said Nataline's funeral was set for 11 a.m. Friday at St. Mary's Armenian Church in Glendale, with burial to follow at Forest Lawn, Hollywood Hills.

lisa.girion@latimes.com

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