United Heathcare Need Not Pay For Patient’s Orthodic Device: In its unreported opinion dated January 5, 2023, the Appellate Court of Maryland ruled that United Healthcare Insurance Co. (“United Health”) need not pay for a patient’s (insured’s) orthotic device to help him regain functional use of his partially paralyzed left arm because that the device falls within a policy exclusion for “Experimental Services.”
Plaintiff was a “covered person” under a health benefits plan (“Plan”) that provides medical benefits through United Health. According to the Certificate of Coverage (“Certificate”), which is part of the Plan’s policy, United Health is obligated to pay benefits for “Covered Health Services.” Covered Health Services is defined in the policy:
Covered Health Service(s) – those health services, including services, supplies, or Pharmaceutical Products, which we determine to be all of the following:
• Medically Necessary.
• Described as a Covered Health Service in this Certificate under Section 1: Covered Health Services and in the Schedule of Benefits.
• Not otherwise excluded in this Certificate under Section 2:
Exclusions and Limitations.
“Section 2: Exclusions and Limitations” of the policy provides, in relevant part:
We do not Pay Benefits for Exclusions
We will not pay Benefits for any of the services, treatments, items or supplies described in this section, even if either of the following is true:
• It is recommended or prescribed by a Physician.
• It is the only available treatment for your condition.
The services, treatments, items or supplies listed in this section are not Covered Health Services, except as may be specifically provided for in Section 1: Covered Health Services or through a Rider to the Policy.
- Experimental Services. This exclusion does not apply to the off-label use of a Prescription Drug Product if such Prescription Drug Product is recognized for treatment in any of the standard reference compendia or in the
medical literature.
The term “Experimental Services” is defined in the policy, in pertinent part, as “services that are not recognized as efficacious as that term is defined in the edition of the Institute of Medicine Report on Assessing Medical Technologies that is current when the care is rendered.” To ascertain whether a service is “experimental,” United Health undertakes a review of its Omnibus Code Policy (“Omnibus Policy”). The Omnibus Policy is developed by United Health’s Medical Policy Team and includes those services that cannot be covered because they are “unproven.” An unproven service is one where there is insufficient medical literature to support its efficacy and safety.
The Appellate Court of Maryland stated in the case it was deciding: “Viewing the evidence in the light most favorable to agency, as we must, we conclude that there was substantial evidence to support the Commissioner’s findings and conclusions. Dr. Tran explained that, in determining whether the exclusion for “experimental services” applies to a request for prior authorization, United Health turns to its Omnibus Policy, which lists services that are considered to be unproven. Dr. Bhatnagar testified that a service is considered unproven if there is insufficient clinical evidence to establish a health benefit for the service. According to Dr. Bhatnagar, United Health’s Omnibus Policy classified the MyoPro as an unproven service because of a lack of well-substantiated clinical evidence to support its use. Dr. Bhatnagar also indicated that the Omnibus Policy on the MyoPro relied on a technology assessment by ECRI, an independent health technology assessment company, that “the evidence was insufficient to determine how well MyoPro works or how it compares with alternate devices intended to improve arm and hand impairment.” Finally, Dr. Bhatnagar testified that she had reviewed the materials submitted by appellant, including various studies, and found no basis on which to change the determination that the MyoPro was unproven. The Commissioner expressly credited the testimony of both Drs. Tran and Bhatnagar … Here, the facts in the record would allow a reasoning mind to conclude that United Health did not violate Maryland law in denying appellant’s prior authorization request for coverage of the MyoPro … there was substantial evidence in the record to support the Commissioner’s decision.”
Source M.M. v. United Healthcare Insurance Co., No. 2039 September Term, 2019.
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